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OPIATE ADDICTION 

Its Handling and Treatment 



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OPIATE ADDICTION 

Its Handling and Treatment 



BY 

Edward Huntington Williams, MJ). 

Formerly Associate Professor of Pathology, State University of 
Iowa ; Associate Editor of the Ency. Brit. (Tenth Edition) ; 
Assistant Physician, New York State Hosp. System ; 
Special Lecturer on Criminology and Mental Hy- 
giene, State University of California ; Author of 
"Mental Hygiene," "The Walled City: A 
Story of the Criminal Insane," "The 
Question of Alcohol," etc., etc. 



i15eto gotfe 

THE MACMILLAN COMPANY 
1922 

All rights reserved 



PRINTED IN THE UNITED STATES OF AMEEICA 






Copyright, 1922, 
By THE MACMILLAN COMPANY. 



Set up and printed. Published March, 1922. 



Press of 

J. J. Little & Ives Company 

New York, U. S. A. 



m 22 1922 
©CLA6S9244 



-w» / 



INTRODUCTION 

About ten years ago the use of narcotics 
/ became the subject of popular agitation in 
vthe United States. There were good rea- n 
sons for this agitation. The responsibility^ 
for a series of spectacular crimes occurring 
in the South was attributed to narcotic ad- 
diction. And criminal acts in varying de- 
grees of atrocity occurring everywhere j 
throughout the country, and with appar- 
ently increasing frequency, $ were laid at 
the door of drug habitues. \ Thus public 
attention was focused upon the evils of 
the abuse of narcotics, and the inadequacy / 
of our legal measures for controlling the 
situation. As a result, the Harrison Nar- 
cotic Law was enacted by the Federal gov-/ 
ernment on December 17, 1914. 

This law was not a hastily conceived 
statute rushed through as an emergency 
measure. On the contrary, it was the 



VI INTRODUCTION 

result of the mature deliberation of per- 
sons intimately familiar with the narcotic 
situation. It was formulated with the 
knowledge and assistance of medical men, 
and of medical associations, thus bearing 
the stamp of approval of the very persons 
who, next to the narcotic users themselves, 
were most vitally affected by its provis- 
ions. For this law placed restrictions upon 
members of the medical profession and, in 
effect, dictated the manner of practicing 
the profession of medicine to an extent 
scarcely approached by any legislation in 
recent years. 

The law not only transgressed ancient 
customs heretofore held sacred to the 
judgment of physicians alone, but made 
it necessary for every physician to 
engage in irksome details and exacting 
clerical work quite foreign to the usual 
medical regime. All this with the approval 
and cooperation of the members of the 
medical profession who appreciated the 
importance of, and the difficulties involved 
in stemming the rapidly rising tide of 
opiate addiction. 



INTRODUCTION Vll 

Nor was it alone those most directly af- 
fected who approved the new statute. Pop- 
ular approval was almost universal. And, 
as would be expected in the case of any 
law having such a background and such a 
backing, this statute became actively oper- 
ative from the day of its enactment. Never 
for one moment has its enforcement been 
neglected. On the contrary, a veritable 
army of specially appointed officials — 
Federal, State, County, and City officials — 
have devoted their energies to the law's 
rigid enforcement. 

From time to time the various courts 
have interpreted certain points in the law. 
And almost without exception these rul- 
ings have tended to tighten the net about 
the narcotic law breakers. There has been 
no trend toward leniency. So that, at the 
present time, practically every prescrip- 
tion written by a physician for a narcotic 
comes under the careful scrutiny of a com- j 
petent inspector; practically every grain \ 
of narcotic dispensed by every pharmacy 
in the land must be accounted for to Fed- 
eral and State inspectors ; and a majority 



Vlll INTRODUCTION 

of the habitual narcotic users are known 
to the authorities even to the extent of 
knowing approximately the amount of 
drug they are taking and the length of 
time they have been taking it. 

Nor is this narcotic knowledge a mere 
formality. Prosecutions of offenders who 
have broken the Harrison Narcotic Law^^l^y 
or are suspected of having done so, fill 
the calendars of the Federal" courts. And" 
other courts are equally well patronized. 

In short, the Harrison Narcotic Law has 
been a popular measure for something 
more than five years, and as actively en- 
forced as is humanly possible. ^ t <k* >s - < h#£i***V 

What is the result of these years of al- 
most unprecedented legislative activity? 

The question cannot be answered in a 
sentence. But it seems to be the con- 
sensus of opinion of Federal, State, and 
County officials, who are most closely in 
touch with the situation, that the number 
of drug takers and the amount of drug 
consumed today, after five years of this 
active legislation, is just as great as, if 



INTRODUCTION* IX 

not, indeed, considerably greater than, it 
was five years ago. - / ) .v 

There is, however, a radical change in 
the method of obtaining opiates by the 
drug addicts. The closure of the legiti- 
mate channels for obtaining narcotics has 
brought into existence an illicit traffic of 
tremendous proportions. The elusive 
underworld "pedlar," well supplied with 
drugs, now exacts his pounds of flesh from 
his helpless victims, and tempts guileless 
"prospects" with free samples for the 
sake of future profits. Thus, without 
vitally affecting the actual evil, we have 
added criminality to what was formerly 
simply immorality. MvMtte^ 

With this situation existing after five 
years of active legislation it behooves us 
to take inventory of our weapons and 
fighting equipment against the narcotic 
evil. Why has the Harrison Narcotic Act 
failed to accomplish the purpose for which 
it is formulated?/ Certainly this failure 
cannot be laid at the door of inactivity on 
the part of officials, or lack of interest and 
cooperation by the public. "Wherefore, it 



X INTRODUCTION 

appears that there must be something 
fundamentally wrong with the inception of 
the law itself. A law that fails to effect 
its purpose when vigorously enforced, and 
after a sufficient length of time to give it 
fair trial, must be lacking in something 
not visualized in its original conception. 
There seems to be no other logical conclu- 
sion. 

From a medical viewpoint the law has 
the fundamental defect of not giving suf- 
ficient consideration to the underlying 
cause of opiate addiction. In effect, it 
regards narcotic addiction as a purely 
criminal act willfully indulged in by 
normal individuals, with only scant con- 
sideration of the possibility that disease 
may be a cause as well as a result of the 
condition. Stated in another way, the law 
emphasizes the legal aspect of the problem 
and subordinates the medical features. 

Now, in point of fact, the vast majority 
of opiate addicts present an abnormal 
mental and physical condition closely akin 
in many respects to the condition known 
as insanity. And our present narcotic 



INTRODUCTIOK XI 

legislation presents many features similar 
to the older legislation for the control of 
mental diseases. 

It is not medical men alone, however, 
who believe that narcotic addiction is often 
the result of an abnormal mental state, not 
merely a "bad habit." The veteran 
officers of the law eventually reach this 
conclusion, almost without exception. In 
the beginning, when their duties first bring 
the officers in contact with this class of 
persons, they usually regard the drug 
addict as a self-willed and responsible 
criminal offender. Their opinion is based 
on the popular conception of addiction, not 
upon practical experience. But later, after 
they have been closely in touch with every 
phase of drug habituation, their viewpoint 
changes almost invariably. Their original 
conception was based on ignorance; their 
later point of view is the result of experi- 
ence. And no one will question that ex- 
perience is a better teacher than ignorance. 

A precisely similar change in mental 
attitude occurs in persons who are brought 
closely in contact with the insane. The 



Xll INTRODUCTION 

novice in insane hospital work invariably 
thinks that a high percentage of his 
patients are not insane — that " there is 
nothing wrong with them." But as he 
gains in experience his viewpoint changes, 
just as in the case of the officers who are 
brought closely in contact with narcotic 
addiction. And thus we find the experi- 
enced narcotic officer inclined to deal 
leniently with the non-criminal type of 
drug addicts, because he realizes that he 
is dealing with persons who are not wholly 
responsible for their shortcomings. 

It is apparent, therefore, that the com- 
parison between insanity and drug addic T f// 
tion is not overdrawn. And in this con- ^/ ytu 
nection we should remember that it is only 
within the lapse of a century that insanity 
has been legally recognized as a disease. 
Christian nations, for a period of more 
than fifteen centuries, had regarded in- 
sanity as a "possession by demons" — a 
crime. The unfortunate insane were im- 
prisoned and subjected to every kind of 
cruelty, just as in the case of the vilest 
criminal. Yet persons continued to be- 






INTRODUCTION Xlll 

come insane, and usually incurably insane, 
in the face of the most hideous punish- 
ments. 

America, the great haven of liberty, 
offered no sanctuary. Lunatics were 
beaten, imprisoned, chained in filthy dun- 
geons and specially maltreated here, just 
as in monarchy- ridden Europe. And as 
a culminating touch of persecution, our 
ancestors burned at the stake that pitiful 
little group of old mad- women at Salem. 

But even this did not stop people from 
"going crazy." And at last even the law 
itself stood aghast at its futile folly. 

Then a great French physician, Pinel, 
proclaimed the heresy that madness is a 
disease, not a crime. And with the cour- 
age of his convictions, and fortunately, 
with an influence that could not be disre- 
garded, he struck the shackles from the in- 
mates chained in their madhouse hovels. 
And behold ! many of these mad creatures 
regained normal reason! The era of ra- 
tional treatment of insanity had dawned. 
Lunacy had evolved from a state of incur- 



XiV INTRODUCTION 

able criminality to the condition of a cur- 
able disease, t ? ^ 44^ titiut&tj*.^****. 

There is an analogy between our present 
attitude toward opiate addiction and the 
lunacy situation of one hundred years ago. 
Insanity was not thoroughly understood 
then, and, naturally, the lunacy laws of 
that time were inadequate and unjust. 

The opiate addict, like the psychopath, is 
an abnormal individual. But in most in- 
stances his physical and mental abnor- 
malities are not apparent to casual obser- 
vation so long as his system is supplied 
with a sustaining quantity of the drug. 
When this necessary stabilizing narcotic 
is withdrawn, however, the abnormal 
physical and mental conditions quickly 
assert themselves with absolute certainty. 
Yet even when the similarity between in- 
sanity and opiate addiction is recognized, 
our attitude toward the two conditions is 
utterly different and is determined by the 
supposed underlying cause of each condi- 
tion, rather than by the conditions them- 
selves. We punish the opiate addict be- 
cause his infirmity is often self-imposed, 



INTRODUCTION XV 

just as formerly lunatics were punished 
because it was believed that they willfully 
associated themselves with evil spirits. 

But the present legal attitude is not con- 
sistent even if we accept the dictum that 
the result of self-imposed vices should be 
punished, while unavoidable misfortunes 
should not. For it so happens that one of 
the most important and prevalent forms 
of insanity, general paresis, is the result 
of venereal vice — a self-imposed condition. 
At least ten per cent, of all cases of in- 
sanity are attributable to this vicious 
cause. Yet the law makes no distinction 
between paretic patients, with their virtu- 
ally self-imposed disease, and any other 
types of insane persons. The paretic is 
not punished, although in acquiring the 
specific infection which is the cause of his 
condition, he gratified a willful indulgence 
scarcely more compelling, and generally 
regarded as far more reprehensible, than 
the craving for a drug. 

It is evident, therefore, that the cause of 
insanity does not influence the legal atti- 
tude toward this disease. Such is not the 



XVI INTRODUCTION 

case with opiate addiction. A drug addict 
is a malefactor in the eyes of the law 
whether he acquired his habit through pure 
viciousness, or whether, as is often the 
case, his addiction was thrust upon him 
unwillingly as in the case of many maimed 
veterans from France. 

It is true that there is a somewhat 
vaguely phrased distinction in the legal 
attitude toward persons who are crimin- 
ally insane and other demented individuals. 
All insanity is a disease, but in some States 
special hospitals are provided for the care 
of persons suffering from "criminal in- 
sanity.' ' But even so, a very great dis- 
tinction is made between this type of in- 
sanity and ordinary criminality. No such 
distinction is made in the case of drug 
addicts. Yet we know that there are 
addicts whose drug taking makes them 
criminals ; and others who regard criminal 
tendencies and criminal acts with just as 
great abhorrence as the highest type of 
normal individuals. It is just as incon- 
sistent to put these persons in the same 
class as it would be to place ordinary crim- 



INTRODUCTION XV11 

inals and insane criminals on the same 
level. 

The important thing about the existing 
narcotic laws, however, regardless of in- 
consistencies, is the fact that they do not 
appear to be getting adequate results. 

One modification of the present law that 
naturally suggests itself is to increase still 
further the scope and stringency of the 
statute. But it would seem that this is 
scarcely possible without curtailing the 
legitimate use of opium. .And opium, bear 
in mind, is our most useful and most im- 
portant drug. Curtailing its legitimate 
use would cause untold suffering among 
countless numbers of innocent persons 
afflicted with painful diseases. These per- 
sons far outnumber the addicts. So that 
even the complete elimination of this rela- 
tively small handful of drug habitues 
would be scant recompense for such a sac- 
rifice. 

A less objectionable plan would be some 
slight modification in the existing narcotic 
laws tending to emphasize the medical side 
of the narcotic problem. There is nothing 



c 






XV111 INTEODUCTION 

novel in this suggestion. Indeed, a prac- 
tical step in this direction was taken in 
certain cities recently. For example, the 
Narcotic Clinics, conducted in the cities of 
Los Angeles and San Diego for a brief 
period in 1920, were based on this prin- 
ciple, and produced results that were en- 
couraging, to say the least. 

The Los Angeles clinic was started as 
a department of the Board of Health, with 
the approval and assistance of the munici- 
pal authorities, for the purpose of giving 
preliminary medical treatment to the nar- 
cotic addicts. This clinic endeavored to 
supply persons who required the constant 
use of an opiate with the necessary amount 
of their narcotic in gradually decreasing 
doses at a nominal price. It was conducted 
by physicians detailed by the Health Com- 
missioner, and under the immediate direc- 
tion of a Narcotic Board composed of 
prominent physicians, public spirited citi- 
zens, and Federal, State, and Municipal 
officers who volunteered their time and 
services. 

It was not the purpose of this clinic 



INTRODUCTION XIX 

merely to supply the opiate addicts of the 
community with narcotics. On the con- 
trary, the clinic was established for the 
purpose of medical treatment, with grad- 
ual withdrawal of the drug, and final cure 
when possible. Complete cure by this 
method would not be possible in most 
cases, of course; but it was possible to 
reduce the amount of drug used, and im- 
prove the patients' physical condition so 
that they could be treated successfully in 
some suitable institution at the proper 
timer %i \ I /U> *+»**i u** - ^*~~-f f>«* 
The things actually accomplished by this 
clinic attained, in a measurable degree, the 
object for which it was created. During 
the five months of its activity, more than 
five hundred drug addicts applied for 
treatment. It was a motley company rep- 
resenting every walk and condition of life. 
Every degree of financial status was rep- 
resented, every shade of dishonesty, as 
well as every grade of intellect. Some 
came from purely criminal motives, others 
with the exalted purpose of being cured of 
their habit. Still others, in the hope that 



XX INTRODUCTION 

they could escape the clutches of the illicit 
pedlar and his extortionate prices. 

A record of the obstacles that had to be 
overcome in putting this experimental 
clinic into practical running order, the mis- 
takes that were made, the trickery and de- 
ceptions that were practiced, as well as the 
honest endeavors of the deserving addicts 
and persons suffering from painful bodily 
afflictions, would make a volume of in- 
tensely interesting and variegated narra- 
tive. But the important things accom- 
plished may be summarized in a few par- 
agraphs. For one thing, illicit peddling 
was reduced to a minimum. When the 
patient could get morphine honestly for 
ten cents a grain, why be dishonest at 
ten times that price with a good chance of 
landing in jail into the bargain? The ped- 
lars complained, almost openly, that they 
were " being ruined" by the Clinic. 

To the class of persons suffering from 
painful afflictions, such as tuberculosis and 
cancer, whose condition made the con- 
tinued use of an opiate an absolute neces- 
sity, the clinic was a veritable Godsend. 



INTRODUCTION XXI 

For it enabled them to procure their neces- 
sary drug at a reasonable price and in a 
legitimate manner. Thus they were able 
to reduce the amount of the narcotic, since, 
curiously enough, the uncertainty of being 
able to get a supply of the drug always 
tends to make the addict use more of it. 
/ The clinic made it possible for several 
individuals to engage in honest occupa- 
tions for the first time in many months. 
Heretofore the uncertainty of the source of 
supply, and the ruinous prices demanded 
by the pedlar, had kept these patients in / 
such a state of physical dilapidation that 
they were unable to work. Thus the 
Clinic enabled many of these victims to 
become again honest breadwinners. Sev- 
eral of them were now able to provide 
for their families and again live in a re- 
spectable and self-respecting manner. And 
meanwhile their general health was im- 
proved by the gradually reduced doses dis- 
pensed at the Clinic, and the release from 
the harassing anxiety about obtaining their 
drug. 

It is a fact well known to persons famil- 



Xxii INTRODUCTION 

iar with the subject, but not appreciated 
by the generality of people, that almost 
every drug addict wishes to be freed from 
his bondage. In many instances the desire 
is an inadequate and feeble one, of course, 
while in others it is insistent and com- 
pelling. The members of the Clinic exem- 
plified this in an amazing degree, all things 
considered. Within two months after 
opening the Clinic, twenty-four individuals 
had made earnest application to be placed 
in some institution for the final treatment 
and cure of their addiction. And it is most 
illuminative that after the Clinic was 
closed no less than twenty-six persons 
were given this curative treatment in pri- 
vate institutions from the accumulated 
funds; and fully as many more had filed 
applications for taking similar treatment 
and were bitterly disappointed when they 
found that no more funds were available. 
This alone, the fact that half a hundred 
persons out of a total of five hundred were 
sufficiently earnest in their desire to be 
cured that they were willing to surrender 
themselves for radical treatment, is con- 



INTRODUCTION XX111 

vincing evidence of the usefulness of this 
experimental Clinic. 

Moreover, the Clinic enabled the officers 
to determine pretty accurately the number 
of drug addicts in the community, particu- 
larly the class of drug takers likely to be- 
come a public menace. And the surpris- 
ingly small number of these individuals 
seems to refute the popular idea that drug ! 
addiction is running riot in our communi- 
ties. 

The fact that so many of these clinic 
patients were anxious to take a final cura- 
tive treatment in some proper institution, 
and that such a relatively large number of 
them actually did so, is an indication of 
what might be accomplished with a clinic 
having hospital facilities at its disposal. 
Such an arrangement is of course the one 
now in vogue for treating almost all 
physical ailments; and even mental dis- 
eases are now so cared for in certain 
favored communities. 

A similar arrangement, modified to meet 
the various conditions, would put the legal 
and medical authorities closely in touch 



XXIV INTKODUCTION 

with the addicted patients and with the 
narcotic situation in a manner similar to 
our arrangements for controlling other 
serious diseases, such as tuberculosis. ; *This 
factor alone, it seems to me, justifies the 
reestablishment of clinics along similar 
lines to the experimental ones tried with 
such a measure of success in Los Angeles 
and San Diego. Undoubtedly great modi- 
fications would be necessary. But great 
modifications are always necessary in any 
progressive experimental work. 

In addition, some special hospital pro- 
visions should be made, just as in the case 
of insanity. And there should be some 
governing body of specially qualified med- 
ical examiners to determine the require- 
ments of each case, similar to the medical 
commissions that determine the status and 
dictate the treatment in insanity cases. 

Unlike the existing laws governing in- 
sanity, however, the final decision about 
any case should not be left to the judg- 
ment of juries composed of laymen. For 
the average layman knows less about 
opiate addiction than he does about the 



INTRODUCTION XXV 

psychoses. And one can scarcely expect 
intelligent assistance and cooperation from 
any body of men who know practically 
nothing about the subject they are called 
upon to decide. 

Perhaps the best practical solution of 
the whole narcotic problem would be to 
place it unreservedly in the hands of the 
United States Public Health Service. This 
would bring it under control of intelligent 
physicians who also have legal authority 
to enforce any clinical or custodial meas- 
ures that seem necessary, and facilities to 
work out its laboratory and clinical prob- 
lems without hindrance. 

In any event, the narcotic addict is with 
us, and like the poor, and the bad, and the 
unfortunate, he is likely to remain with us. 
Only the visionary idealist, or persons 
ignorant of human nature and of human 
history, can believe otherwise. No great 
compelling human vice or disease has ever 
been completely stamped out. And the 
best that we can hope to do by our most 
concerted efforts, for the present at least, 
is to reduce narcotic addiction to a state of 
reasonable control. 



CHAPTEE 1. 

THE NATUEE OF OPIATE ADDIC- 
TION. 



OPIATE ADDICTION 

ITS HANDLING AND TREATMENT 
CHAPTER I. 

THE NATURE OF OPIATE ADDICTION. 

The term "opiate addiction" implies a 
definite pathological condition. The mere 
taking of morphin or heroin, even for quite 
a protracted period, need not necessarily 
constitute addiction. It will lead to it 
eventually and inevitably, of course, but 
the exact length of time required cannot 
be predetermined in any given case. Some 
patients suffering from protracted painful 
conditions may be given opiates for several 
weeks without showing the characteristic 
"withdrawal" symptoms when the drug is 
withheld. They suffer merely from the 
original cause of the pain, not the pains 
caused by want of the narcotic. Others, 
particularly the neurotic type of individ-. 

3 



4 OPIATE ADDICTION 

uals, become addicted very quickly, as 
shown by a rather definite train of symp- 
toms when the administration of the 
opiate is stopped. Indeed, these symptoms 
are so definite in character as to justify the 
term "narcotic drug addiction disease" 
given it by some observers. 

*Bishop recently gave these symptoms, 
and the order in which they appear, about 
as follows : 

There is at first a feeling of uneasiness, 
a " nervousness' ' as the patient expresses 
it, with an increasing sense of depression 
and apprehension of some impending 
calamity. This is followed quickly by 
yawning, sneezing, watering of the eyes 
and excessive mucous secretions from the 
nose. The extremities become cold, and 
there is clammy sweating, nausea, vomit- 
ing, and purging, with tremors and mus- 
cular twitchings. These symptoms accom- 
pany or are quickly followed by intense 
abdominal pains, shooting leg pains, 
cramps, and a general feeling of abject 

* ' ' The Narcotic Drug Problem, ' ' Macmillan Com- 
pany, 1920. 



THE NATURE OF OPIATE ADDICTION O 

misery and dilapidation. In this condition 
the pulse rate varies between extreme 
slowness and extreme rapidity, usually 
with a marked drop in the blood pressure. 
In short, the patient looks, acts, and is a 
very sick as well as a very miserable in- 
dividual. And occasionally he justifies his 
appearance by collapsing and passing on. 
These symptoms appear in just about 
the sequence given in a very high percent- 
age of patients; but there are, of course, 
all manner of variations in individual 
cases. Thus, one patient describes his first 
withdrawal symptoms as feeling as though 
his ears were tunneled out — a feeling as if 
some instrument had bored out two cav- 
ities from his throat to the ears, the cav- 
ities resounding with weird noises and dis- 
agreeable sensations. Another patient has 
a boring pain in the left elbow as the first 
indication of withdrawal. Still another 
loses control of the sphincters at the very 
beginning of the withdrawal of the nar- 
cotic before there are any other symp- 
toms whatsoever. And one might multiply 
this list almost indefinitely. Yet even the 



D OPIATE ADDICTION 

patients of this class eventually develop 
pretty much the same sequence of symp- 
toms as those just described, even though 
their initial symptoms are different. 

The peculiarity of this withdrawal con- 
dition is that it is relieved almost instantly 
by even a very small dose of narcotic. 
When relief is not at hand, however, these 
symptoms continue and increase in inten- 
sity for a period of time ranging from 
about thirty-six hours as the minimum, to 
an extreme limit of about five days. The 
average time would be perhaps sixty 
hours. And during that time the patient 
suffers the very limit of mental and 
physical agony. Indeed, the Inquisition 
missed what would certainly have been one 
of its choicest torture-devices by passing 
out of fashion before morphin came in. 

This picture of the withdrawal symp- 
toms in cases of drug addiction is not an 
overdrawn one. And even after this 
period of acute distress is passed the 
patient's troubles are not ended by any 
means. He will still be obsessed by mental 
cravings for the drug at times, and occa- 



THE NATUKE OF OPIATE ADDICTION 7 

sional attacks of stabbing pains will come 
as very tangible reminders. It is not until 
these painful sensations and the craving 
for the drug have entirely disappeared 
that the patient can be considered as clin- 
ically cured. 

But even though this patient is appar- 
ently entirely free from all opiate addic- 
tion symptoms, and returned to a normal 
condition, he is not really so in point of 
fact. His system still remains sensitized 
to the action of opiates. And if at any 
time in the future, even after several years, 
he is given a few doses of any opium prep- 
aration he is likely to exhibit the charac- 
teristic symptoms of narcotic addiction dis- 
ease. Thus it may happen at any time that 
these former drug-users may become the 
innocent victims of ignorant or careless 
medication. Indeed, many of them are thus 
victimized. I have personal knowledge of 
cases of recurrent drug addiction that were 
precipitated by cough mixtures, prescribed 
by physicians, which contained small doses 
of an opiate. 

The clinical picture presented by these 



8 OPIATE ADDICTION 

various groups of withdrawal symptoms is 
that of a definite pathological disturbance. 
The toxic action of the opiate is neutral- 
ized by some substance prepared for this 
purpose in the body (call it an "antitoxin' ' 
if you will, for convenience) and in such 
definite amounts that an artificial balance 
closely approximating normality is estab- 
lished. This balance is maintained only 
by the administration of a definite amount 
of the accustomed narcotic, the exact quan- 
tity differing, of course, in each individual. 
Too much or too little of the narcotic dis- 
turbs the balance, and complete withdrawal 
causes the violent symptoms just de- 
scribed. 

These symptoms, then, are actual phys- 
ical symptoms. I wish to emphasize this 
because the impression prevails quite gen- 
erally outside of medical circles that drug 
addiction is merely a "habit" — a thing 
that is "all in the patient's mind." This 
is a mistake. And, it so happens, it is a 
mistake that the Christian Scientists have 
been very helpful in demonstrating. For 
sooner or later, particularly in communi- 



THE NATUEE OF OPIATE ADDICTION \) 

ties where the Christian Science bug is 
rampant, quite a high percentage of drug 
addicts take a fling at this so-called mental 
healing. But, so far as I have been able to 
learn, no drug addict has ever been cured by 
this particular variety of innocuous ther- 
apy. There is no dose of mental treatment 
strong enough to counteract the terrible 
nausea, depression, and stabbing, boring 
pains that follow morphin withdrawal. 

There is, of course, a marked psychic 
element in all cases of narcotic addiction. 
Many opiate addicts are of the unstable 
type, usually with a background of bad 
heredity that accounts for such cases. In 
a way, then, such addicts are born, not 
made — that is, born with an inherent and 
fundamental mental instability which 
makes them crave some form of stimulant 
or narcotic. 

We have a closely similar analogy in in- 
ebriety. There seems to be no question 
that constitutional instability is responsi- 
ble for practically all cases of inebriety. 
The mere matter of being able to obtain 
alcoholic drinks easily is not the real rea- 



10 OPIATE ADDICTION 

son why a few persons are inebriates while 
the majority of people are not. For, until 
recently, alcoholic beverages were about 
the cheapest and most available things on 
the market. Yet the majority of people 
did not become inebriates, just as most per- 
sons do not become gluttons simply be- 
cause there is an abundance of food. 

So with drug addiction. There was a 
time when narcotics could be obtained any- 
where and by any one for a few cents. Yet 
the percentage of drug addiction was no 
higher than at present — indeed, it was not 
nearly so high if we may place any de- 
pendence upon statistics. And thus it is 
a natural inference that drug addiction, 
like inebriety, is not merely the result of 
the abundance of the substance that pro- 
duces the condition. 

As a matter of fact, since many of the 
present day addicts were formerly in- 
ebriates, it is a natural inference that ad- 
diction has been increased, in a measure at 
least, by the fact that alcoholic beverages 
are so expensive and so difficult to obtain 
at present. They are also conspicuously 



THE NATURE OF OPIATE ADDICTION 11 

bulky for transportation, while narcotics 
are temptingly condensed. 

There is this marked difference between 
inebriety and drug addiction : Inebriety is 
often a periodic affair, with long intervals 
of total abstinence intervening. Such is 
not the case with drug addiction. There is 
no such thing as a "periodic" drug addict. 
Once the victim has become "hooked," he 
must have his particular narcotic continu- 
ously and in fairly uniform doses. And he 
must do this, not in order to "get on a 
jag," but to maintain himself at something 
that approaches the normal human level. 

Another fact that suggests mental in- 
stability of most addicts is that many of 
them are abnormal, actually insane, even f 
when cured of their addiction. I am not 
referring here to the psychoses that are 
occasionally produced by narcotics, but to 
a psychosis that exists both before and 
after the treatment for drug addiction, and 
undoubtedly would have developed inde- 
pendently of the drug habit. In some cases 
it appears that the psychosis itself is re- 
sponsible for the addiction. 



12 OPIATE ADDICTION 

While it is true that many drug addicts 
are of the mentally unstable neurotic type, 
this is not true of all cases. Any person, 
regardless of his constitutional make-up, 
will become a narcotic addict in the true 
sense of the term if opiates are adminis- 
tered continually for a sufficient length of 
time. To be sure, the neurotic type is much 
more susceptible than the stable, well bal- 
anced individual, and as a rule is much 
more difficult to cure of the addiction. 

These are the cases that seem naturally 
to "gravitate" into one kind of vice or 
another, and become narcotic users with- 
out any tangible reason for doing so. 
Frequently they acquire their habit by 
taking a few experimental " shots' 9 with 
convivial friends, only to find themselves 
firmly "hooked" as a result. When the 
more stable type of individual becomes an 
addict, however, it is almost invariably as 
the result of some painful affliction which 
required the continued use of an opiate. 
In other words, there is usually a much 
more tangible excuse for his addiction than 
is the case with the neurotic individual. 



THE NATURE OF OPIATE ADDICTION 13 

It is well known, of course, that the 
initial doses of opium produce very dif- 
ferent sensations in different individuals, 
just as is the case with alcohol. The 
neurotic person is the one likely to be 
easily intoxicated and elated by his first 
experience with an opiate, while no cor- 
responding sensation, or at least only in 
a very mild degree, is experienced by the 
more stable type of individual. Thus, one 
type of patient experiences the craving 
for a pleasurable sensation that the other 
does not, and is more readily victimized 
by the drug. But, in the last analysis, no 
person is immune to opiate addiction. 

There is well-grounded skepticism every- 
where as to the possibility of effecting a 
permanent cure in any case of established 
drug addiction. The answer to the ques- 
tion as to whether or not a permanent cure 
is ever possible depends entirely upon 
what is meant by the word "cure." With- 
out question it is possible to treat certain 
cases so that for many years the individual 
will not take any opiate, and will be free 
from any desire to do so. But, as was 



14 OPIATE ADDICTION 

indicated a few pages back, the patient 
does remain sensitized to narcotics even 
though there is no indication of this con- 
dition, and thus has a greater suscepti- 
bility to the acquirement of the addiction. 

In this respect there is a similarity be- 
tween this condition and a condition pro- 
duced by other toxic substances, such as 
the poison of rhus. The poison oak victim 
may be cured, in the generally accepted 
sense of the term, although he will always 
remain more likely to infection than his 
neighbor who has never been poisoned. 
And if it is proper to speak of an individ- 
ual being " cured'' of rhus poisoning, then 
we may very properly refer to drug addic- 
tion as a curable condition. 

However, no one familiar with the sub- 
ject will attempt to deny that most opiate 
addicts eventually revert. The aphorism 
expressed by most officers of the law, 
"Once an addict always an addict," may 
not express an absolute truth, but is not 
very far wrong as applied to the under- 
world habitues. 



CHAPTEE II. 

GRADUAL REDUCTION TREATMENT 
OF DRUG ADDICTIONS. 



CHAPTER II. 

GRADUAL REDUCTION TREATMENT OF DRUG 
ADDICTIONS. 

There seems to be no difference of opin- 
ion among clinicians that slow reduction 
is not the "method of choice" in the treat- 
ment of drug addictions. Indeed, some 
observers assert that cures can never be 
effected by this method, and that it should 
never be attempted. Such extreme views, 
however, are not based upon demonstrable 
facts. The only debatable point is whether 
or not the method is even advisable. 

The Federal Government at the present 
time frowns upon any form of ambulatory 
treatment of drug addiction — that is, any 
treatment that is attempted outside of a 
hospital or some institution in which the 
patient is under constant care and super- 
vision. And this attitude is entirely con- 
sistent with existing laws which, theoretic- 

17 



18 OPIATE ADDICTION 

ally at least, give the government complete 
control of every grain of narcotic that is 
purchased, used, or dispensed. Theoret- 
ically the drug addict can obtain no nar- 
cotic without the knowledge and consent 
of the Federal authorities. And it is theo- 
retically possible, therefore, for the Gov- 
ernment to dictate the form of treatment 
that each addict shall undergo. Wherefore 
the Government naturally selects the best 
form of treatment, which is the hospital 
treatment under careful supervision. 

Unfortunately, there is a wide discrep- 
ancy between theory and actuality in this 
case. As yet the Government has been 
unable to make actual conditions con- 
sonant to the theoretical one. So that while 
it is theoretically impossible for the addict 
to obtain his narcotic without the knowl- 
edge of the authorities, in point of fact he 
is able to obtain the drug clandestinely 
almost everywhere in this country, the 
amount of his purchase being limited only 
by the limits of his pocketbook. 

This fact has created a situation which 
must be combatted by practical temporary 



GRADUAL REDUCTION TREATMENT 19 

methods until a more ideal one can be de- 
veloped. In other words, the existing con- 
dition may justify the acceptance of the 
"half loaf " since the "whole loaf" seems 
not to be obtainable at the present time. 
The gradual reduction treatment of ambul- 
atory cases should be regarded simply as 
a "half loaf" expedient, because there are 
many drug addicts who cannot, or will 
not, accept hospital treatment for their ad- 
diction. And if other treatment is refused 
them, they will keep themselves supplied 
with their narcotic through illicit chan- 
nels. 

In such cases we are confronted with 
the problem of deciding whether it is 
better to give the patient an inferior form 
of treatment with the possibiltiy of curing 
him, or to refuse the treatment absolutely 
with the knowledge that in that event he 
will continue in his addiction, breaking 
laws to obtain his narcotic, and encourag- 
ing other lawbreakers by doing so. 

There is another feature of the treatment 
of ambulatory cases by the gradual reduc- 
tion method that makes this treatment a 



20 OPIATE ADDICTION 

very dubious one in most instances. I 
refer to the deception in the matter of 
getting prescriptions. Thus, it is a com- 
mon practice for the dishonest addict to 
patronize several physicians at the same 
time, using different names and telling a 
different story in each instance, and thus 
obtaining enough narcotic to keep himself 
and his friends or patrons well supplied. 

All these various things have created a 
situation that makes the authorities sus- 
picious and skeptical — a situation that 
works a great injustice and hardship on 
the deserving and decent addicts, and 
jeopardizes the standing of the honest but 
sympathetic physician. Meanwhile the dis- 
honest and degenerate addict is able to 
secure as much narcotic as he wishes 
through underground channels; and the 
unscrupulous physician finds various ways 
of carrying on his nefarious practices. In 
short, deserving unfortunates may be made 
to suffer, while the unscrupulous criminal 
who has created the situation goes scot- 
free. And until this situation is changed 
— until the distribution of narcotics is 



GRADUAL REDUCTION TREATMENT 21 

under actual, not merely theoretical con- 
trol — it will not do to disregard the fact 
that there are some cases of drug addic- 
tion that deserve great sympathy as well 
as the many cases that deserve permanent 
penitentiary residences. 

For example, one must bear in mind 
always the type of cases in which the drug 
addiction is simply supplemental to some 
other disease, such as tuberculosis. In 
many cases of heroin taking, for example, 
the victim began using the narcotic to re- 
lieve the tubercular cough. And in many 
such cases, particularly where the original 
malady has not been entirely conquered, 
the gradual reduction method of treatment 
to overcome the addiction is often prefer- 
able to any sudden withdrawal method. 

As a rule, of course, any patient who can 
be treated successfully by the gradual re- 
duction method can be treated with equal 
success, and perhaps more satisfactorily, 
by one of the "sudden withdrawal" 
methods. There are exceptions to this 
rule, however. For example, I have on 
record two cases in which the * * sudden re- 



22 OPIATE ADDICTION 

duction" method had failed, twice in the 
case of one patient and three times in the 
other. Yet both these patients were finally 
cured by a systematic reduction and sub- 
stitution process, and remained free from 
their addiction for a period of at least two 
years and three years respectively to my 
personal knowledge. So far as I am able 
to learn, they are still free from it. 

One of these cases is worth considering 
somewhat in detail. She was an intel- 
ligent, rather emotional type of well edu- 
cated and cultured woman upon whom a 
hysterectomy had been performed just at 
the beginning of the menopause period. 
At that time she had been addicted to the 
use of morphin for about five years, having 
used the drug originally for the relief of 
pain in the pelvic region. Following the 
operation, and at intervals of from six to 
eight months, she had been given treatment 
for the cure of her addiction in three dif- 
ferent sanitariums, and by three different 
"sudden withdrawal" methods. The phy- 
sicians who attempted these treatments 
were men of skill and experience in each 



GRADUAL REDUCTION TREATMENT 23 

instance. Yet in each instance the pa- 
tient's physical and mental condition had 
become so precarious that the physicians 
found it impossible to complete the treat- 
ment. 

Immediately following the last of these 
abortive attempts, her physician, a skilled 
internist, decided to proceed along an en- 
tirely different line. He outlined a plan, 
with the full coordination of the patient, of 
having the usual number of hypodermic in- 
jections administered daily. These were 
to be given by the husband. 

The exact amount administered after 
the initial dose at the beginning of the 
treatment was not to be known to the 
patient. She understood that a very 
gradual reduction was to be made and that 
the treatment would extend over several 
months; but she was to remain in igno- 
rance as to details. 

On the assumption that the patient was 
suffering from endocrine depletion, she 
was given a mixture of the extracts of 
adrenal and thyroid glands, with spermin 
extract combined with glycerophosphates 



24 OPIATE ADDICTION 

and strychnia. These were administered 
daily throughout the treatment. 

At the time of beginning treatment the 
patient was taking five grains of morphin 
daily. This was reduced at the uniform 
rate of one-sixtieth of a grain each day, 
which represented merely a change of 
1/240 of a grain per dose during each 
twenty-four hour period. 

The minuteness of this amount of reduc- 
tion seems too inconsequential for serious 
consideration. But one must bear in mind 
the history of this case, a history of three 
failures by ordinary methods of treatment. 
Moreover, results sometimes justify seem- 
ingly absurd as well as extreme measures. 
It was so in this particular case. For, 
although at the end of the second month 
the patient had been reduced only one 
grain from the original five, and at the 
end of the fourth month only two grains, 
it developed that at the end of ten months 
she was completely off the narcotic. But 
this was then unknown to her, as she was 
taking regular doses of a solution of 



GKADUAL REDUCTION TREATMENT 25 

strychnia in place of the narcotic, and was 
in excellent physical and mental condition. 

A month later all medication was dis- 
continued and she was released from the 
bondage of the needle an entirely healthy 
and an exceptionally happy individual. 

I have cited this case in detail as an 
example of what may be done when neces- 
sity demands it. The method was cer- 
tainly not an ideal one. Yet in extenua- 
tion it may be pointed out that it suc- 
ceeded where other methods had failed. 
And meanwhile the patient suffered prac- 
tically no discomfort during the slowly pro- 
tracted course of the drug withdrawal. 

When we reflect that opiate addiction 
is centuries old, it will appear that methods 
of treating these afflictions must be almost 
as aged and that physicians have disagreed 
for years about methods of treatment. In 
point of fact the physicians of at least fifty 
years ago were divided in their opinions 
about the methods most suitable for treat- 
ing drug addicts just as they are today. 
There were at that time ardent advocates 



26 OPIATE ADDICTION 

of sudden and complete withdrawal, and 
equally ardent advocates of some form of 
gradual reduction. The advocates of sud- 
den withdrawal of that period were handi- 
capped by the lack of substitute drugs 
which are now available. And. therefore, 
from a purely clinical point of view, the 
gradual reduction advocates had some- 
what the best of it. ' ' Sudden withdrawal ' ' 
as practiced at that time consisted in lock- 
ing the man up and forcing him to "kick 
it out," as it is termed in the vernacular, 
just as is done in some of our jails today. 
And some of those patients died just as 
some of them do at the present time when 
this radical method is attempted. 

On the other hand, some of the methods 
of gradual withdrawal as practiced suc- 
cessfully by the physicians in the last gen- 
eration are still worthy of consideration. 
They had at least the important merit of 
being successful. For example, in one of 
the large asylums for treating the insane 
in the Middle "West, a method of treating 
the drug addicts sent to the institution was 
used thirty-five years ago with very uni- 



GEADUAL REDUCTION TREATMENT 27 

form success. At that time the use of the 
hypodermic needle had not become uni- 
versal as it is at present, so that most of 
the patients under treatment were accus- 
tomed to taking their drug by mouth. A 
certain number of them, however, took the 
drug hypodermically. But whatever their 
method of taking the drug, the manner of 
treatment as practiced in this institution 
was practically the same in all cases. 

In the matter of length of time required 
for completing treatment the method was 
a compromise between sudden withdrawal 
and our present conception of gradual re- 
duction treatment. A stock solution of 
morphin and strychnin was made up, the 
proportions being such that each hypoder- 
mic dose of morphin represented one- 
quarter the amount of the patient's neces- 
sary daily dosage and also a full dose of 
strychnia. This was administered at reg- 
ular six-hour intervals, so that in the be- 
ginning the patient received his full 
amount of narcotic in the course of twenty- 
four hours. At the same time he was given 
a tonic of iron and quinin; and good 



28 OPIATE ADDICTION 

elimination was maintained by the use of 
cascara and salines, with baths and packs 
as his condition suggested. He was also 
given easily assimilated food at frequent 
intervals when he could take it. 

If the patient was in fairly good phys- 
ical condition the reduction of the mor- 
phin was started immediately. This was 
done by replacing each dose of the mor- 
phin and strychnin solution by an equal 
amount of sterilized strychnin solution. 
Thus, the patient was shifted gradually 
from full doses of morphin hypodermically 
until finally he was taking simply full 
doses of strychnia at his regular six hour 
intervals. When necessary to combat in- 
somnia and nervousness the patient was 
given a solution of bromides and chloral — 
the "B and C" sedative mixture which 
was popular in institutions at that time. 

Of course the patient was kept in igno- 
rance of the amount of drug he was getting, 
the strychnin in the solution facilitating 
the deception. For, as is well known, many 
addicts are able to detect the presence or 
absence of morphin in a hypodermic solu- 



GEADUAL REDUCTION TREATMENT 29 

tion by the "feel of the needle, " as they 
express it. Indeed, this sense is so keenly 
developed in certain patients that they can 
tell at once, without waiting for the effect 
of the drug, whether the solution admin- 
istered hypodermically really contains any 
morphin. But frequently this keenness in 
detection is dependent upon the amount of 
morphin the patient is taking. For this 
reason it is more difficult to deceive a 
patient with a "sterile hypo" at a time 
when he is taking considerable quantities 
of the drug than it is later on in the process 
of reduction when he is getting only 
minute doses of the opiate. And when 
strychnin is added to the solution of mor- 
phin, and the mixture given for some time, 
the keenness in detecting the morphin by 
the "feel of the needle" becomes so dulled 
that most patients finally reach a stage at 
which they cannot distinguish between a 
hypodermic dose containing only strychnia 
and one that contains morphin also. Thus, 
the strychnin acts not only as a tonic and 
helpful eliminant, but also assists in the 
camouflage practice of withdrawal. 



30 OPIATE ADDICTION 

In the method of gradual withdrawal 
just referred to, the usual time required for 
treatment, or at least to complete the entire 
withdrawal of the morphin, was between 
two and three w ee ks. And during this 
period the patient suffered a minimum 
amount of distress and discomfort, no 
more, indeed, than is felt in most of the 
recent methods of treatment. Moreover, 
after the first week the patient usually 
began to gain in strength, appetite, and 
general condition. 

It is understood, of course, that this 
treatment was not discontinued for some 
little time after the morphin had been com- 
pletely withdrawn. Indeed, the regular 
hypodermic doses at six-hour intervals 
were continued for at least two weeks 
longer, thus building up the patient's 
physical condition. 

In most instances, of course, this treat- 
ment could not be carried to completion 
without variation or incident in the ideal 
manner outlined here. There were likely 
to be times of impending collapse, just as 
during the course of any other form of 



GKADUAL REDUCTION TREATMENT 31 

treatment, and the development of unex- 
pected symptoms which required constant 
medical vigilance and skill. Nevertheless, 
the treatment was usually successful, 
spared the paitent the physical tortures of 
withdrawal, and later lessened the mental 
torments of craving for the drug that 
always follow when withdrawal is accom- 
plished without some definite medical aid. 
Needless to say, the chances of success 
in this treatment were greatly enhanced by 
the fact that it was administered under 
ideal conditions. The patient was under 
lock and key in a hospital where there was 
every facility for giving treatment, and an 
available number of trained assistants. 
Almost any form of treatment would have 
been successful under the circumstances — 
that is, successful in the sense that the 
patient could have been kept from taking a 
narcotic. But this was not only successful, 
but also lacking in the elements of discom- 
fort that attend the harsher methods. It 
was, in fact, simply a " gradual reduction" 
treatment carried out under hospital super- 
vision. Yet it was in no sense an "am- 



32 OPIATE ADDICTION 

bulatory" form of treatment which allows 
the patient to go about his daily affairs, 
and, for this reason, is not the type of 
treatment generally referred to as the 
gradual reduction form. 

WHY SHOULD GRADUAL REDUCTION BE AT- 
TEMPTED AT ALL? 

Looked at from almost any angle, the 
gradual reduction method of treating am- 
bulatory cases of drug addiction is a com- 
promise. But compromises are the rule 
rather than the exception in the practice of 
medicine — no less so in treating drug ad- 
dictions than in other fields. We treat at 
least twenty cases of sickness outside of 
hospitals for every case treated in a hos- 
pital. Yet we know that hospital treat- 
ment is better treatment, the ideal one. 
And we accept the inferior method simply 
because of expediency that amounts to 
necessity. 

So with narcotic addictions. And it is 
quite as unjust to refuse helpful treatment 
to the type of deserving addict who is un- 
able to take hospital treatment, as it would 



GRADUAL REDUCTION TREATMENT 33 

be to refuse "home treatment" in a case of 
pneumonia, syphilis, or carcinoma. 

We have in this country at the present 
time thousands of drug addicts who are 
wholly blameless for their affliction, and 
who are eager to free themselves of this 
curse. For example, many of our soldiers 
in France were given narcotics to save 
them from the agonies of German gases, — 
young, vigorous, upright Americans, who 
offered their lives for humanity, who are 
now bearing an affliction incomparably 
worse than the wounds received on the 
firing line. No adequate provision has been 
made for treating these unfortunates by 
government, states or cities. And until 
such provisions are made it is a reproach 
to our boasted humanity to refuse these 
sufferers the chance for recovery, even 
though the method employed is not an 
ideal one. 

An illustrative case is that of a soldier 
who was severely gassed a few days before 
the Armistice, was placed in one of the 
army hospitals for treatment. He was in 
a desperate condition, suffering agonies, 



34 OPIATE ADDICTION 

and was given large doses of morphin over 
quite a protracted period to relieve this 
condition. When he finally recovered suf- 
ficiently to be discharged from the service 
he had become addicted to the use of mor- 
phin. 

He was an intelligent young man, with- 
out hereditary taint so far as could be 
learned, and the absolute antithesis of that 
type of individual who seems naturally to 
degenerate into some form of addiction. 
He was married and had a family depend- 
ent upon him, was upright, industrious, 
and eager to be cured of the " habit.' ' 

Two or three weeks of treatment in a 
sanitarium was suggested. But this would, 
of course, require a considerable outlay of 
money and necessitate the patient giving 
up his employment for a certain period 
of time. As he had no money in reserve, 
with his family dependent upon him for 
support, this sanitarium treatment was out 
of the question. 

The second course open to him was to 
give himself up to the county authorities 
and receive free treatment. In order to 



GEADUAL REDUCTION TREATMENT 35 

do this, however, he would be obliged to 
sign a "voluntary commitment" and go to 
the Psychopathic Hospital. There he 
would be brought before a judge and sen- 
tenced to one of the State hospitals for the 
insane for a period not exceeding two 
years. 

The third alternative was to take some 
form of ambulatory gradual reduction 
treatment that would allow him to continue 
his work for the necessary support of his 
family. 

Sanitarium treatment was quite out of 
the question, as has been stated, on ac- 
count of the lack of funds. The second 
alternative, that of going to one of the 
State insane hospitals, can hardly be con- 
sidered as desirable, or a just one in his 
case, when viewed from whatever angle. 
If for no other reason, the fact that his 
family would be without means of support 
during the period of his incarceration, 
made it impossible. But there is another 
deterrent: Every patient who has been a 
public charge confined in an insane hos- 
pital is a "marked man" in the eyes of his 



36 OPIATE ADDICTION 

business associates. For, regrettable as it 
is, the fact remains that any person whose 
condition has made it necessary for him to 
be a patient in an insane hospital is per- 
manently stigmatized in the eyes of the 
world. This is unfortunate, utterly unjust. 
Nevertheless it is the fact. And it is use- 
less to attempt to deceive ourselves by any 
sophistical arguments to the contrary. 

The case of this young soldier illustrates 
one type of narcotic addict that must 
be reckoned with in our communities, 
although, of course, only a very small per- 
centage of such cases are the result of mil- 
itary service. But many of them are just 
as innocent of wrong-doing, or evil inten- 
tions of any kind, as the boys who were 
gassed on the battle fields in France. And 
a certain percentage of these cases, who 
find it impossible to take sanitarium treat- 
ment, are entitled to any form of treatment 
that will help to free them of their addic- 
tion without either subjecting their family 
to hardships or placing a permanent public 
stigma upon them. 



GRADUAL REDUCTION TREATMENT 37 

However, it is not alone the stigma of 
being shut up in an insane hospital that 
deters the addict from taking treatment 
in some of our public institutions. It is 
really a distrust of the treatment itself — 
the fear and belief on the part of the addict 
that he will not receive the care, skill, and 
attention that are necessary to cure him of 
his habit without an almost unbearable 
amount of suffering. For it is common 
knowledge among all narcotic takers that 
our public institutions are not equipped to 
give individual attention to patients 
during the protracted hours of suffering 
as is the case in well paid private institu- 
tions. Also, that most of the public insti- 
tutions depend upon the lock and key as a 
means of treatment, rather than upon 
medication that mitigates and shortens the 
suffering. The difference between these 
two methods is not unlike the difference 
between performing an operation with an 
anesthetic and without one. The narcotic 
addict knows about all these things to the 
minutest detail, and is suspicious of public 



38 OPIATE ADDICTION 

institutions and public institution methods. 
Even an addict hates to be hurt unneces- 
sarily. 

As a matter of fact, his suspicions are 
well grounded. Very few of our public in- 
stitutions have a sufficiently generous 
equipment of physicians and nurses to en- 
able them to give the same careful and 
practically painless treatment to the drug 
addiction cases that is possible in private 
institutions. And until such provision is 
made one can hardly blame the addict for 
his entirely human attitude of mind, par- 
ticularly when we reflect that even the 
vilest criminal is given the benefit of an 
anesthetic when an operation is necessary. 

SELECTED CASES FOE GEADUAL EEDUCTION" 
TEEATMENT. 

Obviously, the percentage of drug ad- 
dicts that may be treated successfully or 
who should be treated by the gradual re- 
duction method is a small one. All addicts 
of the criminal type are ruled out of this 
small company. So, also, is the proverbi- 
ally weak-chinned type of individual, fre- 



GRADUAL REDUCTION TREATMENT 39 

quently a harmless and irresponsible crea- 
ture and often a fantastic dreamer — the 
"sissy" type that is often addicted to nar- 
cotics. Such individuals are naturally de- 
fective in mental stability, and their opiate 
addiction is simply one manner of demon- 
strating their inadequacy for which an- 
other method will be substituted if they 
are deprived of the drug. These are cases 
for custodial care as well as therapeutic 
measures. 

There is usually no physical reason, of 
course, why persons of this class should 
not respond successfully to this treatment. 
Indeed, it seems to be true that most of 
them, at one period or another, — even the 
actually criminal type — wish to be cured 
of their addiction. But such desire cannot 
be measured in the terms of normal will- 
power. They are guided by the currents 
in the channels of least resistance; and if 
it were easier to get off the drug than to 
keep on using it they would be glad to be 
rid of their inconvenient habit; otherwise 
not. 

In addition to this large company of 



40 OPIATE ADDICTION 

actual degenerates there is also quite a 
company of drug users who are so influ- 
enced by their surroundings and the bad 
company they keep that any attempt to 
cure them of their habit excepting by isola- 
tion is hopeless. Some of these cases, if 
placed in different surroundings, could be 
treated successfully by gradual reduction 
methods. And when one of them shows 
sufficient intelligence and sincerity to 
change his surroundings and his associates 
voluntarily, he becomes at once a hopeful 
case. 

Of course, a great number of persons 
who present themselves for treatment are 
in such a state of physical dilapidation 
that it would be dangerous to attempt to 
cure their addiction without a period of 
preparatory treatment to improve their 
general condition. Such cases are usually 
the ideal ones for gradual reduction treat- 
ment, not as a curative measure, but as 
preliminary to the final withdrawal treat- 
ment. For it is usually true in these cases 
that they are not only taking more narcotic 
than is necessary to maintain their phys- 



GRADUAL REDUCTION" TREATMENT 41 

ical balance, but frequently their method 
of taking the drug is utterly inadequate. 
The usual fault in such cases is too fre- 
quent and too irregular dosage of the nar- 
cotic. But under proper supervision it is 
often possible to reduce the daily dosage 
very quickly to one-half or even a quarter 
the original amount, at the same time 
building up the patient's resistance and im- 
proving his physical condition generally. 

In every group of narcotic addicts of 
any considerable size there are sure to be 
a few individuals whose physical condition 
or natural physical make-up is such that 
it is impossible to cure them by any form 
of gradual reduction treatment. They can 
be reduced gradually to a certain point, but 
when the amount of their narcotic is cut 
below that point they show the physical 
symptoms of withdrawal continuously for 
days and weeks regardless of what sub- 
stitute substance may be administered. 
This condition is illustrated by the history 
of the following case : 

The patient in this instance was a man 
in good physical condition, thirty-six years 



42 OPIATE ADDICTION 

old, who gave a history of having been 
rather a heavy drinker at one period in his 
life and who, ten years before, had been 
addicted to the use of morphin for a period 
of two years. He had taken treatment, how- 
ever, and had kept aw T ay from the drug 
for a period of about seven and one-half 
years. At the time of seeking treatment 
he had been using morphin for about ten 
months, having renewed his habit as a 
result of family difficulties, unhappiness, 
and general disgust with the world which 
placed him in a " don't care" attitude of 
mind. 

Shortly after renewing his addiction, 
however, his domestic and financial affairs 
cleared up, so that he now had a com- 
pelling incentive to be rid of his habit. In 
desperation he resorted to the classical 
method of attempting to "kick it out" by 
shutting himself in his room for several 
days of torture. And with the usual result 
— failure. However, he had managed to 
reduce his dose and modify his manner 
of taking the drug so that at the time of 



GRADUAL REDUCTION TREATMENT 43 

coming under observation he was taking 
only one grain "of morphin daily. 

Here was a case that would seem to be 
an ideal one for any kind of treatment 
whatsoever. Yet, in point of fact, although 
various methods of gradual reduction 
treatment were tried for a period extend- 
ing over six weeks, it was impassible to 
withdraw the drug completely. The patient 
cooperated in every way possible, and for 
one period of ten days without remission 
suffered constant symptoms of withdrawal 
of the drug with all the attendant discom- 
fort without asking for relief or attempt- 
ing to obtain it. And when finally he was 
placed in a sanitarium for treatment his 
case proved to be an unusually intractable 
one. 

I cite this case merely to illustrate the 
fact that in cases of drug addiction, just as 
in the treatment of all other ailments, one 
can never predetermine whether the treat- 
ment of any individual case will be easy or 
difficult. Generally speaking, however, 
patients who are inherently unstable men- 



44 OPIATE ADDICTION 

tally are proportionately harder to treat 
than those, for example, who began taking 
the narcotic for the relief of some physical 
ailment. But in any event, there must be 
an earnest desire to get off the drug, not 
merely a vague wish engendered by bodily 
inconvenience or fear. 

The isolated cases of drug addiction 
found in the country, or in villages, and 
away from the great centers of population 
are much more hopeful for treatment of 
any kind than the urban habitues. There 
are several reasons for this, the most im- 
portant being the ease with which the drug 
is obtained in the cities, and the matter 
of bad associates. In the country dis- 
tricts drug using is usually a solitary prac- 
tice of a single individual, whereas in the 
cities the drug users of the young or under- 
world class know each other and associate 
together. In these groups there is a clan- 
nish fellowship and a generosity which 
prompts the addict to share his portion 
with his fellow-sufferer or assist him in 
obtaining the drug. More than that, there 
is often a diabolical type of jealousy which 



GKADUAL REDUCTION TREATMENT 45 

makes the addict resent his neighbor's 
efforts to be freed of his curse when he 
himself is still under its ban. As a result, 
a patient under treatment who comes in 
contact with other narcotic users is sure 
to have temptation thrust upon him. 

Even though the drug is not offered him 
openly, his craving is constantly stimu- 
lated by the knowledge that his associates 
are having their cravings gratified. In- 
deed, the mere knowledge that his friend 
has the narcotic in his possession stimu- 
lates a desire for a "shot" that is almost 
irresistible. And the sight of his neighbor 
actually taking a hypodermic, or the 
knowledge that he has gone to some retir- 
ing room for the purpose of doing so, pro- 
duces a craving of an intensity that is 
entirely incomprehensible to the normal 
individual. For this reason it is utterly 
futile, except by isolation, to attempt to 
cure one member of a family when another 
member is continuing to use the narcotic. 

In small communities the disturbing 
element of convivial associates is usually 
lacking. Furthermore, in these small com- 



46 OPIATE ADDICTION 

munities the individual's personal affairs 
are known to a wider circle of acquaint- 
ances, and his actions more keenly watched 
than in large cities. For this reason it is 
far more difficult to conceal family skele- 
tons in rural districts. Everybody knows 
his neighbor in the country, and knows 
something about his neighbor, whereas in 
the city no one knows or cares much about 
any one outside his immediate circle of 
friends. Thus it follows, since it is more 
difficult to conceal one's shortcomings in 
village life, that the element of individual 
self-respect is on a more elevated plane in 
small communities. Even the rural drug 
addict exemplifies this in his attitude 
toward his "bad habit" and his greater 
willingness to cooperate in overcoming it. 
The vicious type of narcotic addict is sel- 
dom found in small communities. He is 
essentially a city-dweller, and is for the 
most part a product of city life. 

TREATMENT BY GRADUAL WITHDRAWAL. 

Since the process of becoming addicted 
to the use of narcotics is a gradual 



GRADUAL REDUCTION TREATMENT 47 

one, it is a natural inference that the re- 
verse of this process — the method of with- 
drawal by gradual reduction of the nar- 
cotic — would be the ideal method of treat- 
ment. As has been pointed out, however, 
this is not the case in most instances. 
There are so many complicating factors 
that cannot be measured in terms of exact 
science — so many factors that cannot be 
explained at all except empirically — and 
methods must be judged by results rather 
than by theoretical considerations. 

Bishop expresses the consensus of opin- 
ion of clinicians as regards the gradual 
reduction treatment, in a sentence. "In 
my opinion,' ' he says, "all other consid- 
erations aside, there are very few who are 
possessed of sufficient understanding of 
narcotic addiction and ability in the inter- 
pretation of clinical indication, and have 
the technical skill required to carry it 
through to a clinically successful culmina- 
tion.' ' In my experience, and as Bishop 
also states, the term "technical skill" re- 
quires a very broad interpretation. It 
really requires no more skill to treat cases 



48 OPIATE ADDICTION 

of drug addiction than it required for the 
successful treatment of pulmonary or gas- 
tric conditions. It is merely a matter of 
knowledge and experience. Most physi- 
cians have a well rounded knowledge of 
general diseases, whereas the average 
physician knows very little about opiate 
addictions. It is a field almost entirely 
foreign to his routine experience. 

The special clinical knowledge required 
for the successful treatment of drug addic- 
tions would include a very full understand- 
ing of human nature, both normal and ad- 
dicted, a knowledge of the action of certain 
drugs, combined with a willingness to take 
infinite pains and give sustained attention 
to details. This is a somewhat formidable 
combination. But, given this combination, 
I see no reason why any practitioner of 
medicine should not treat successfully cer- 
tain selected cases of drug addiction by the 
gradual reduction process. For, after all, 
these same qualities are necessary to suc- 
cessful treatment, whether the method be 
by sudden withdrawal or gradual reduc- 
tion. 



GRADUAL REDUCTION TREATMENT 49 

Apparently the most successful methods 
of gradual reduction treatment are those 
based upon some process of substitution, 
that is, some combination of drugs in 
which the amount of the accustomed nar- 
cotic is gradually lessened while, at the 
same time, some other substance is used 
that in a measure replaces the effect of the 
narcotic, The only drugs that will produce 
this effect are the preparations of opium 
itself, and no one of these in exactly the 
same degree as the others. Thus of the 
four educts, heroin, morphin, codein, and 
dionin (ethyl morphin hydrochlorid), the 
two first, heroin and morphin, are the 
"strong arm" members of the family, 
while codein and dionin, although they 
have a similar effect, really have this effect 
in a very weak and attenuated form. 
Heroin and morphin are the alkaloids that 
more readily relieve pain, produce the 
"jag" effect in the novice, and the ones re- 
sponsible for narcotic addiction. And they 
are the substances responsible for these 
conditions when the whole drug, opium, is 
taken. Such a thing as "codein addic- 



50 OPIATE ADDICTION 

tion," or "dionin addiction, ' ' is practically 
unknown. 

Yet, if neither heroin nor morphin is 
available, the habitue can get a somewhat 
similar effect — can at least avert the worst 
phases of withdrawal suffering — by large 
doses of either codein or dionin. He would 
not have his suffering and craving entirely 
relieved, but would have them very de- 
cidedly mitigated. And if the use of these 
drugs were continued, he would presently 
reach a stage in which he would be com- 
fortable and without the old craving so 
long as his system was saturated with 
codein or dionin. This condition would be 
a very decided step toward recovery, be- 
cause codein and dionin do not produce a 
" habit' ' of any such intensity as do mor- 
phin or heroin, and may be quickly reduced 
and withdrawn without any very great dis- 
comfort to the patient. 

In the gradual withdrawal method by 
substitution, the idea is to replace the de- 
creasing quantity of the more powerful 
narcotic with constantly increasing quan- 
tities of the less powerful ones, taking suf- 



GRADUAL REDUCTION TREATMENT 51 

ficient time in making this change so that 
the patient does not suffer intolerable dis- 
comfort. In practice this may be done suc- 
cessfully in certain cases ; but, as has been 
said, and will be reiterated, it can only be 
done in a limited number of cases out of 
the entire army of opiate habitues, and 
then only by skillful, sustained, and pains- 
taking effort. 

To avoid any misunderstanding, it 
should be stated that, aside from the opium 
educts, there is one other group of drugs 
that alleviate the suffering and craving of 
opiate withdrawal. This is the atropin 
group, with hyoscin as the drug best suited 
for this purpose. But in order to produce 
this effect it is necessary to give the 
hyoscin in sufficient doses to make the 
patient delirious, or semi-delirious. In 
other words, to " knock him out," or make 
him very "groggy." Short of this, his suf- 
ferings are not relieved. And as it is a 
hazardous thing to produce this semi- 
delirious condition in ambulatory cases, 
the atropin group of drugs should not be 
used in the gradual reduction form of 



52 OPIATE ADDICTION 

treatment. Under hospital supervision, 
however, there need be no such restrictions 
about their use. 

As was referred to a moment ago, the 
substitution process in the reduction treat- 
ment must be a very gradual one at every 
stage. Also it must be done with the 
earnest cooperation of the patient, and had 
best be without his knowledge about exact 
details. For the psychic element in the 
treatment of these cases seems to be quite 
as important as the medication. And if 
the patient is allowed to watch prescrip- 
tions, and knows that day by day his accus- 
tomed drug is being replaced by a less 
effective one, he is sure to become panicky 
and apprehensive. The effect is like watch- 
ing the clock tick off the moments to some 
inevitable catastrophe. The suspense of 
watching is worse than the catastrophe 
itself. And thus the same patient who is 
perfectly comfortable on a daily dosage of 
unknown quantity will develop the pains 
and other symptoms of withdrawal if he 
knows the actual amount he is getting. 

Regardless of the amount the patient is 



GKADUAL REDUCTION TREATMENT 53 

using, it is sometimes desirable to shift 
him from hypodermic to oral medication 
where this is possible. For the "needle 
habit" of itself — the "feel" of the needle 
— is in some cases almost as much of an 
"addiction" as the contents of the syringe 
itself. This yearning is much more pro- 
nounced in some patients than in others, 
but in some cases in which the narcotic is 
taken hypodermically the needle is part of 
the addiction. 

However, there are some cases in which 
it is impossible to change to oral medica- 
tion on account of some conditions, such 
as gastric disturbance. Frequently these 
cases are the ones in which the narcotic 
addiction is supplemental to some other 
disease, like phthisis; but as the cure of 
these cases is usually dependent upon the 
treatment of the original disease, the 
narcotic habit is not likely to be intrac- 
table. 

In any event, when the change is made 
from hypodermic medication to oral, it is 
a wise plan to increase the patient's daily 
narcotic allowance about twenty-five per 



54 OPIATE ADDICTION 

cent, at the start. Otherwise he will miss 
the accustomed relief given him by the 
needle and will be too sorely tempted to 
discontinue treatment, or to resort to dis- 
honesty. 

Sometimes it is expedient to combine the 
two methods of administration. If so, it is 
a good plan to have the hypodermic mix- 
ture contain the greater part of the total 
amount of the narcotic administered, com- 
bined with some other substance, prefer- 
ably strychnin. In some patients, how- 
ever, strychnin used hypodermically acts 
as an irritant, producing painful " lumps" 
at the site of the injection, and in such 
cases it may be omitted and codein or 
dionin substituted in increasing quan- 
tities as the amount of morphin or heroin 
is decreased. But, whatever the substitute, 
it is highly important in the scheme of 
treatment not to give a plain morphin and 
water solution as the hypodermic mixture. 
Because, as has been pointed out, most pa- 
tients know the "feel" of morphin or 
heroin, and at the period of final with- 



GRADUAL REDUCTION TREATMENT 55 

drawal will be able to detect the absence 
of either of these narcotics unless some 
other substance is present in their hypo- 
dermic mixtures. But if codein or dionin 
has been added to the mixture, and the 
amount gradually increased while the 
amount of morphin or heroin is steadily 
decreased, the patient gradually loses his 
ability to sense the "feel" of the morphin. 
At first he recognizes that there is a dif- 
ference in the solution he is taking, but 
since it gets the desired effect he disre- 
gards this; and gradually he loses the 
keenness in his ability for detection. 

Another detail that is often most essen- 
tial to the success of this form of treat- 
ment is that of arranging so that the pa- 
tient receives exactly the same bulk of 
hypodermic solution in all stages of the 
treatment regardless of the amount of 
drug contained in the solution. If the pa- 
tient is taking twenty minim doses five 
times a day, for example, this amount of 
liquid should be given at the accustomed 
intervals of administration, and main- 



56 OPIATE ADDICTION 

tained throughout the treatment. And 
some corresponding method should be pur- 
sued in oral medication. 

Such trivial details may appear to the 
novice as absurd and entirely unnecessary. 
But clinical experience with these cases 
shows that Michael Angelo's rule about 
trifles applies to the treatment of drug 
addiction quite as much as to the making 
of masterpieces in art. ' ' Trifles make per- 
fection," said Angelo, "but perfection it- 
self is no trifle." In these cases the "per- 
fection" sought is a patient cured of his 
habit. And if kindly and sustained atten- 
tion is not paid to the psychic element, 
with its combination of whims and trifles 
in most patients, a firm but kindly attitude 
towards the higher sensibilities as well as 
to the lower planes of physical discomfort 
— we cannot attain even that degree of per- 
fection represented by the reformed drug 
habitue. 

Bear this fact constantly in mind : a drug 
addict "cured" against his will is not 
really cured at all no matter what method 
of treatment is used or how long he may 



GRADUAL REDUCTION TREATMENT 57 

be incarcerated. Wherefore, throwing men 
into jails or keeping them in confinement 
where they cannot get the drug for weeks 
or months, never cures them, or rarely so. 
Almost every member of the various col- 
onies for treating addiction, although en- 
tirely free from the physical craving for 
the narcotic, is looking forward and count- 
ing the weeks, days, and hoars when he 
shall be free — free to get a "shot." And 
the reason for this is in the main that 
such forms of treatment give scant atten- 
tion to the mental part of the patient's 
ailment, which frequently becomes the 
dominant one when antagonized or disre- 
garded. There is lacking in all such meth- 
ods of treatment the element of kindly in- 
terest and personal attention that is abso- 
lutely necessary even for temporary suc- 
cess in handling these cases. 

In referring to this,, Bishop makes the 
following significant statement which 
should be taken to heart by every physician 
attempting to handle drug habitues : 

1 ' The personal attitude of the physician 
towards opiate addicted patients is of great 



58 OPIATE ADDICTION" 

importance. The medical man who is to 
treat a case suffering from addiction-dis- 
ease successfully to the end of relieving 
this condition, or who is treating addic- 
tion-disease as an intercurrent condition 
complicating another disease, must first 
of all make his patient realize that the 
physician himself knows something about 
addiction as a disease. He must never give 
his patient any hint or reason to suspect 
that he regards opiate addiction as a habit, 
a vice, a degrading indulgence, which can 
be to any curative or even therapeutic ex- 
tent combatted by the exercise of will- 
power/ ? 

The physician who handles these cases 
must be neither martinet nor mollycoddle 
in the opinion of his patients. If he is born 
disciplinarian he will be neither of these, of 
course. But, in any event, the successful 
practice of medicine implies kindness and 
firmness on the part of the physician. And 
it requires no particular exaggeration of 
these necessary qualities for the success- 
ful handling of opiate-produced diseases. 
Yet the term, firmness, as used here does 



GRADUAL REDUCTION TREATMENT 59 

not imply an inflexibility of mind that will 
not allow the physician to deviate from 
any fixed rules of treatment which the in- 
dividual case may demand. 

As to medicine, strychnin is, in my opin- 
ion, the most useful single drug in treating 
narcotic addiction by the gradual reduc- 
tion process. There is a definite physio- 
logical reason for this. Narcotic drugs not 
only check glandular activity and inhibit 
the activity of the unstriped muscles, but 
they tend to derange and arrest all meta- 
bolic processes. Thus they check peristal- 
sis and interfere with elimination. For 
this reason the chronic addict is sure to 
have his system clogged by an accumula- 
tion of toxic substances; and the use of 
strychnin aids materially in correcting this 
condition. Frequently its effects are quick- 
ly noticeable as shown by the improved 
appearance of the patient, better appetite 
and general feeling of euphora. 

In treating these cases, one need feel no 
hesitancy in giving large doses of strych- 
nin. For narcotic addicts are notoriously 
tolerant to drugs of all kinds, and it is al- 



60 OPIATE ADDICTION 

most impossible to give an "over-dose" of 
anything to a patient that has been long 
addicted to narcotics. An accurate history 
of the huge doses of drugs of all kinds that 
have been taken by addicts, at one time 
or another, without producing any harmful 
effects, would tend to disrupt our ideas of 
medical dosage. For example, a nurse- 
addict observed by me, completed a sur- 
reptitious raid on the medicine closet by 
drinking four ounces of a mixture contain- 
ing fifteen grains of sodium bromid and 
five grains of chloral hydrate, to the dram 
— 480 grains of sodium bromide and 160 
grains of chloral, beside several other 
drugs. After which she became happily 
unconscious and rolled down a flight of 
stairs where she remained most of the 
night. She received no treatment, and was 
apparently all right and ready for more of 
her narcotic the following afternoon. 

This is only one of many similar cases 
that could be cited showing the immunity 
of drug addicts to ordinary medication. 
All of which is very comforting to the 
cautious clinician on occasion when he is 



GRADUAL REDUCTION TREATMENT 61 

fearful of having given an overdose of 
something. There is little danger of err- 
ing in that direction when treating drug 
habitues. 

In most cases of drug addiction there 
is a marked tendency to acidosis and con- 
stipation, as would be expected. To cor- 
rect this, liberal doses of milk of magnesia 
as a routine are helpful. Or, as an alterna- 
tive, thirty to sixty grain doses of sodium 
bicarbonate in combination with cascara. 
The old rhubarb and soda mixture is use- 
ful also, but less so than the cascara and 
soda combination. 

AN ILLUSTRATIVE CASE. 

The following case (No. 380), which is 
given graphically for convenience, is that 
of the young soldier referred to a few pages 
back whose treatment was successful at the 
end of two months, and who did not lose 
a single day's work during that period, or 
suffer any very great discomfort. It 
will be seen from this record that in the 
beginning the patient was given a daily 
dosage of three grains of morphin and one 



62 OPIATE ADDICTION 

grain of codein combined with strychnin. 
He had been taking four grains of morphin, 
but this was cut to three grains, and one 
grain of codein substituted and the strych- 
nin added. All this without the patient's 
knowledge, of course. 

Thereafter there was a gradual shifting 
from the morphin to the codein, the 
amount of codein added each day corre- 
sponding exactly to the amount of morphin 
deducted. Meanwhile there was a slight 
increase in the amount of strychnin, until 
the patient was getting one-eighth of a 
grain daily. But there was no change in 
the amount of water used in making the 
solution, and no change in the number of 
hypodermics taken daily by the patient or 
in the amount of the liquid taken at each 
dose. 

In this manner the shift was gradually 
made from morphin to codein, so that in 
five weeks after beginning the treatment, 
the patient received his last dose of mor- 
phin, but was getting almost four grains of 
codein daily at that time. Following this, 
the amount of codein was gradually re- 



GRADUAL REDUCTION TREATMENT 63 

duced until twenty days later the daily 
amount was a little less than one grain, an 
amount too insignificant for serious con- 
sideration in a patient once accustomed to 
large doses of morphin. 

Such proved to be the case here, for the 
patient was in excellent spirits, had gained 
about ten pounds in weight, and his only 
complaint was a restlessness, with bad 
dreams at night. There were no real with- 
drawal symptoms. All things considered, 
therefore, it was thought advisable to let 
the patient know the true status of things, 
and he was told that he had been getting 
no morphin for three weeks. At the same 
time he was given eight powders of lu- 
minal-sodium, containing one-half grain 
each, with instructions to take one powder 
hypodermically at bed time. Each powder 
was to be dissolved in a half teaspoonful 
of water and the solution boiled before 
using it. 

A week later the patient reported that 
he had slept well every night since his last 
visit, that he was feeling fit physically, and 
was elated over the fact that he was no 



64 OPIATE ADDICTION 

longer a drug habitue. When informed of 
the exact date at which the morphin was 
absolutely discontinued, he stated that he 
had no intimation of the fact from his feel- 
ings. The codein and strychnin com- 
bination had acted as an efficient substi- 
tute. 

Such being the case, one naturally 
wonders whether it would not have been 
possible to substitute codein for morphin 
in the beginning of the treatment. We 
know from experience that this would not 
have been possible without producing in- 
tolerable withdrawal symptoms. It is only 
when the accustomed amount of morphin 
has been greatly reduced and the patient 's 
system well fortified, that it is possible to 
substitute the codein, and even then the 
amount given must be greatly in excess of 
the daily dosage of morphin. But when 
the substitution has been made and con- 
tinued for a few days the amount of codein 
can be reduced very quickly, since it does 
not grip the patient as does morphin, and 
when the amount taken is small, is not f ol- 



GKADUAL REDUCTION TREATMENT 65 

lowed by withdrawal symptoms when it is 
stopped entirely. 

It will be noted in the case just referred 
to, that the combination of narcotic and 
other drugs were prescribed in solutions, 
not as tablets or powders. There are 
several definite reasons for this. For one 
thing, and the most important, is the fact 
that the daily amount of the solution used 
remains the same throughout the treat- 
ment, thus giving the patient no clue, as 
far as mere bulk is concerned, as to the 
quantity of drug he is taking. But there 
is another reason for prescribing solutions, 
which is not so apparent to the uninitiated. 
This is that, if the patient is dishonest, and 
frequently he is, he will find it more dif- 
ficult to dispose of a solution which ap- 
pears to be simply plain water than a 
tempting white powder or familiarly 
shaped tablets. This possibility should al- 
ways be borne in mind. Moreover, a patient 
is less likely to have his pockets pilfered of 
an innocent looking vial of water than he 

[Continued on page 68 



EXPLANATION OF CHART NO. 380. 

This chart, which is an actual page from 
the case record, is in epitome the entire 
record of treatment. Each line represents 
the day's prescription, and when read from 
left to right gives the date of the prescrip- 
tion, the amount of morphin and other 
drugs, the amount of water used in the 
solution, and the number of days for which 
the prescription is made. Thus at a glance 
it is possible to tell the exact amount of 
each drug given in the preceding prescrip- 
tion, and as the treatment progresses the 
vertical column shows the rate at which the 
narcotic is being reduced, the rate of in- 
crease of the substitute, and the time being 
consumed by the treatment. It is a simple, 
convenient, and practical method of keep- 
ing records that need occupy only the space 
of one page for each patient. 



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68 OPIATE ADDICTION 

would be if he were carrying an opiate 
mixture in solid form. Also, there will be 
less danger of needle infections when 
sterile solutions are used than when 
powder or tablets are made into solutions 
by the patient, with the characteristic care- 
lessness or ignorance of the average addict. 

To be sure, solutions are likely to be 
spilled, and small bottles broken accidently. 
There is the temptation of having fictitious 
spills and breaks. But, on the whole, the 
advantages outweigh the disadvantages, 
and the danger of serious loss can be min- 
imized by dividing the solution into the 
daily amounts placed in separate vials. 

An ideal method of prescribing and dis- 
pensing would be in ampoules containing 
single doses of each. But this is not pos- 
sible ordinarily. 

For all practical purposes prescriptions 
written for an amount sufficient to last 
one day, or at most two days, are satis- 
factory. If larger amounts are given, that 
is, amounts in excess of three days at most, 
the patient is almost sure to take an over- 
dosage on the first day or two and thus be 



GRADUAL REDUCTION TREATMENT 69 

shortened and tempted into dishonesty for 
the later days. 

Here again we are dealing with appar- 
ently insignificant details. But they are 
far more likely to seem insignificant to 
persons who have had small experience 
with this class of patients than to the 
thoroughly orientated physician. Those 
who are familiar with such cases are aware 
that it is the "infinite taking of pains" 
with these cases that is often the key to 
success. 

In this connection, the matter of keeping 
the patient in ignorance of the contents of 
his prescription is also an essential detail. 
To give the patient a prescription with 
instructions not to look at its contents and 
expect him to follow such instructions, 
would be an evidence of abysmal ignorance 
of human nature. And it is folly to sup- 
pose that the patient will not be able to de- 
cipher the prescription if it is formulated 
in Latin terms and medical signs. For 
practically every patient has a very com- 
prehensive knowledge about almost every- 
thing that concerns his misfortune. Par- 



70 OPIATE ADDICTION 

ticularly so in recent years, since stringent 
laws and active officials have forced the 
narcotic users into secret underworld clans 
in which velvet garments rub elbows with 
rags, but acquire vast narcotic-addiction- 
wisdom as a result of this disgusting con- 
tact. 

For this reason the physician who is 
prescribing for these cases should have 
some practical method of meeting these 
conditions in a manner that does not con- 
flict with State or Federal laws. For ex- 
ample, he must bear in mind the fact that 
the Federal law now requires that each 
prescription be indorsed on its back by the 
person receiving the medicine from the 
druggist. This necessary indorsement may 
give the patient an opportunity of seeing 
the contents of his prescription at the 
pharmacy, when he is handed the prescrip- 
tion to sign, even though no such oppor- 
tunity is given him in the physician's 
office. This can be obviated by having the 
patient indorse the back of a folded pre- 
scription in the presence of the physician 



GRADUAL REDUCTION TREATMENT 71 

or nurse, after which it is placed in a 
sealed envelope. 

Even with this precaution, however, 
there is still another manner in which the 
patient may determine pretty accurately 
the amount of narcotic he is taking unless 
some method is devised to prevent it. I 
refer to the price that he pays for each 
prescription. If the amount of solution 
he gets from the drug store each time is 
the same, and yet the price gradually 
dwindles, he will naturally infer, and cor- 
rectly, that the diminishing price is an 
index to the lessened amount of the nar- 
cotic in his prescription. He expects this 
cutting down process, and wishes it. Yet, 
in the later stages of treatment when the 
amount of morphin is very small, the pa- 
tient's frame of mind will be much better if 
he is kept in ignorance of the exact con- 
tents of his prescription. This may be done 
by arranging with the dispensing phar- 
macist so that the patient is charged a uni- 
form price for his prescription regardless 
of contents. 



72 OPIATE ADDICTION 

For this reason, as well as for several 
other excellent ones, it is well in the be- 
ginning of the treatment to have the 
patient select a responsible pharmacy at 
which his prescriptions are to be filled and 
to patronize this pharmacy only. With 
this arrangement it is a simple matter to 
keep the patient in ignorance about the 
amount of drug he is taking unless he re- 
sorts to dishonest methods. And in that 
event he is not a fit subject for treatment 
except under custodial care. It is hopeless 
to attempt to treat any patient who will 
resort to flagrant dishonesty, and the sug- 
gestions given here are to eliminate as 
much as possible the minor temptations for 
the class of patients who are willing hon- 
estly to cooperate with the physician. 

Another important detail in this method 
of treatment is the regulation of the 
number of daily doses, as well as the 
amount of the daily dosage. Generally 
speaking, it is better to have the patient 
take a few doses at long intervals than it 
is for him to take numerous doses at short 
intervals even when the actual amount of 



GRADUAL REDUCTION TREATMENT 73 

narcotic taken during the twenty-four 
hours is the same. It is on the principle 
that "three square meals" a day are better 
than continual nibbling. Many drug ad- 
dicts have made this discovery for them- 
selves — have discovered that frequent 
doses of small amounts do not "hold 
them" as well as large doses taken at 
longer intervals. And there are many pa- 
tients who have arranged so that they take 
only two doses daily, one in the morning 
and one at night. In such cases the treat- 
ment is much more hopeful, as it indicates 
a certain mental stability and intelligence, 
and is also an indication that the patient's 
will power is not utterly shattered. 

There is a direct relationship between 
the amount of drug taken and the length of 
time its effects are prolonged. To be sure, 
it is not true that if one grain of morphin 
will keep a patient comfortable for four 
hours, two grains will keep him comfort- 
able for eight hours, and three grains for 
twelve hours; but in most cases if one 
grain will keep him comfortable for four 
hours, two grains will have the same effect 



74 OPIATE ADDICTION 

for about seven hours, and three grains for 
about nine hours. And meanwhile, when 
the narcotic is taken into the system at 
long intervals only, the various processes 
of metabolism which are temporarily re- 
tarded almost immediately even by small 
doses of the narcotic, tend to establish 
their normal functions some little time be- 
fore the crying need of his narcotic is felt 
by the patient. For this reason, patients 
who are taking their drug at long intervals 
are usually in better physical condition 
and with better physical resistance than 
the ones who are nagging at small amounts 
of the drugs at short intervals. 

This explains why it is better for the 
patient to take his narcotic regularly, and 
with as long intervals intervening as pos- 
sible. And in actual practice it appears 
that about the only hopeful cases are the 
ones who are taking or can be taught to 
take their narcotic in this manner. On the 
other hand, individuals who are obliged to 
take more than four doses of narcotic daily 
are not hopeful cases for gradual reduc- 
tion treatment, as a rule. 



GRADUAL. REDUCTION" TREATMENT 75 

GRADUAL. REDUCTION TREATMENT BY ORAL. 
ADMINISTRATION. 

Wherever it is possible, it will be found 
advisable to shift from the hypodermic 
administration to the oral, for reasons that 
have been referred to before. This is not 
an easy matter in most cases. But, curi- 
ously enough, it is frequently easier to 
discontinue the use of the needle in old 
habitues who have smoked opium at one 
time or another than in recent cases who 
have never taken the narcotic except by 
the hypodermic method. Even when the 
addiction is of many years ' standing, I find 
this to hold true as a general rule. 

Perhaps this may be explained by the 
assumption that in cases of recent addic- 
tion we have a double habit to combat, 
"needle habit" and the drug addiction. 
These are combined and inseparable in the 
patient's mind, the sensation of the prick 
of the needle being followed almost imme- 
diately by the sensation of the opiate. It 
is this combination of sensations that is 
craved by the needle addict — the positive, 



76 OPIATE ADDICTION 

instantaneous effect that he associates 
with his habit, and which is not produced 
by the slower method of internal adminis- 
tration. 

In the older addicts, who formed their 
habit either by opium- smoking, laudanum- 
drinking, or one or another of the slower 
methods of absorbing the narcotic, there 
is not quite the same attitude of mind 
towards the needle as with the more recent 
opiate users. If they have been taking 
opium by one of these slower methods for 
some little time before beginning the hypo- 
dermic administration of the drug, they 
will have passed the stage where narcotic 
exhilarates or intoxicates as it does in the 
early stages of administration. They are 
not expecting a "kick" or a repetition of 
the early "pipe dreams," but merely take 
the drug to bring them up to what is now 
their normal level in physical and mental 
condition. To them the "shot" is merely 
a rapid and convenient and absolutely cer- 
tain method of obtaining what, in former 
years, they were able to obtain by the more 
laborious and slower methods. In short, 



GRADUAL REDUCTION TREATMENT 77 

they are not " addicted" to the needle with 
any such degree of tenacity as is the per- 
son who knows of no other method of 
taking the narcotic. 

This explains, I believe, why it is usually 
easier to shift the older habitues to the oral 
administration of their narcotic than those 
who are in effect novices. But, in any 
event, when this shift is once made we will 
have a much easier problem to solve ; and 
in my experience the reduction and com- 
pletion of the treatment can be shortened 
very greatly when the method of oral 
treatment is used. 

The following case (No. 297) will illus- 
trate the feature just referred to (see page 
78). 

In this case the patient was forty-five 
years old and had been taking narcotics 
off and on (mostly on, of course), for over 
twenty years. At the time of beginning 
treatment he was taking three grains of 
morphine daily hypodermically and had 
been doing this, practically without varia- 
tion in the amount in the daily dosage, for 
over two years. Apparently that amount 



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GRADUAL REDUCTION TREATMENT 79 

was just sufficient to keep him in good 
physical condition, for he was well nour- 
ished and his bodily functions working 
normally. 

His incentive for taking treatment was 
twofold, neither "fold" being in the least 
tainted by "higher ideals" or an exalted 
moral sense. Stated precisely, the two 
reasons for his change of heart were, first, 
that his family had promised definitely to 
leave him, and second, the Federal author- 
ities had made quite as definite promises 
to press certain matters that were then 
pending unless he stopped using the drug. 

I mention these things as showing the 
importance of an impelling incentive. Had 
this man been influenced simply by the 
feeble, weak-kneed desire to be cured of 
his habit, which most addicts exhibit at 
one time or another, it would not have been 
possible to reduce his dosage so rapidly 
and to effect a cure in such a compara- 
tively short time. 

Referring to the course of treatment in 
detail, it will be seen that the patient was 
given a mixture of nux vomica and one of 



80 OPIATE ADDICTION 

the so-called digestive elixirs in which the 
morphin was held in solution. The nux 
vomica was given for the double purpose 
of adding bitterness to the taste and for 
its usual therapeutic effect, and the diges- 
tive elixir was used as a vehicle and with 
the general idea of averting any gastric 
disturbance. An extra grain of morphin 
was added to the daily dosage at first so 
as to maintain the narcotic balance which 
requires more of the drug when given 
orally than when taken hypodermically. 
The amount of morphin was then reduced 
day by day until at the end of ten days 
the patient was getting less than half the 
amount of his narcotic than in the begin- 
ning. 

As the patient continued to be in good 
physical condition during this reduction, 
the morphin was still further reduced and 
codein added in increasing doses while the 
amount of morphin was steadily decreased. 
Finally the morphin was stopped at a point 
where both the amount of morphin and 
the amount of codein had been greatly 
reduced; but when this was done the 



GEADUAL REDUCTION TREATMENT 81 

amount of codein was doubled and, at the 
same time, hyoscin and pilocarpin in rather 
vigorous doses were added to the mixture. 
Following this, the amount of codein was 
gradually reduced without any change 
being made in the other ingredients until 
finally it was omitted entirely. Then the 
amount of hyoscin and pilocarpin was 
lessened, and this mixture continued with- 
out change for a period of three weeks. At 
the end of that time the patient was found 
to be cured of his addiction and required 
no further treatment. 

During the course of treatment there 
was no period at which the patient felt 
quite up to his usual physical and mental 
standard ; but, on the other hand, there 
was no time at which he experienced any 
very great discomfort. And during the 
last ten days of the treatment he was in 
excellent physical condition and stated 
that he felt better than he had for several 
years. During the entire time he was, of 
course, entirely ignorant of the contents 
of his prescription; and he stated later 



82 OPIATE ADDICTION 

that he had no inkling from his feelings 
when the final wrench of discontinuing his 
narcotic was made. 

Although the treatment worked success- 
fully and in an ideal manner in this par- 
ticular case, there are some features of it, 
particularly the latter stages, when hyoscin 
and pilocarpin were added, which made it 
rather hazardous except in carefully 
selected and closely observed cases. Thus, 
it is not advisable in most ambulatory 
cases, unless those cases are under direct 
hospital supervision, to prescribe hyoscin 
or any of the preparations of hyoscyamus. 
For although hyoscyamus and its deriva- 
tive alkaloids do counteract the craving for 
morphin when given in large doses, there 
is always danger of their producing a 
mental condition that is in effect a tem- 
porary psychosis which may prove dis- 
astrous if the patient is not under super- 
vision and control. The physiological 
effects may be counteracted to a certain 
extent by the use of pilocarpin, as in this 
case. And in this case the reason for 
giving hyoscin while the patient was con- 



GRADUAL. REDUCTION TREATMENT 83 

tinuing his usual occupation was a knowl- 
edge of the patient's general make-up, and 
the fact that he was under rather close 
observation, and also that he had been sat- 
urated with various drugs for years. For 
it is a matter of common observation that 
there seems to be little danger of giving 
an overdose of almost anything to these 
supersaturated addicts. They are im- 
mune to such a degree that one need have 
very little apprehension of producing 
alarming symptoms. 

In any event, the use of hyoscin, par- 
ticularly in the beginning of treatment 
when the patient is taking large quantities 
of the narcotic, is of very doubtful value 
in cases undergoing gradual reduction 
treatment. It is of very great value, of 
course, in cases taking special treatment 
under hospital supervision. But even in 
such cases it is necessary to push the drug 
until a certain definite physiological effect 
is produced, as anything short of this dos- 
age does not relieve the morphin with- 
drawal symptoms. Indeed, such symptoms 
are not relieved until the patient is in a 



84 OPIATE ADDICTION 

state verging on delirium, and naturally 
it would be unwise to produce such a con- 
dition in an ambulatory case. However, 
when the amount of the narcotic has been 
greatly reduced, small doses of hyoscin do 
apparently lessen the patient's discomfort 
in some cases. Apparently it did so in the 
case just referred to, and certainly no bad 
symptoms or effects were produced. 

Generally speaking then, it is not advis- 
able to use any preparation of hyoscyamus 
in cases undergoing gradual reduction 
treatment. Not on account of the alleged 
ill-effects alone, but because small doses 
are of little value. It is a case when a 
logical theory does not work out in prac- 
tice. Logically, since large doses prevent 
withdrawal pains and discomfort, small 
doses should do so in a proportionate de- 
gree. But such is not the case in most 
instances. 

As a matter of fact, hyoscin is some- 
thing of a medical bugaboo. Many medical 
men seem to regard its action as peculiarly 
dangerous and clouded with mystery, 
largely because they have little occasion 



GRADUAL REDUCTION TREATMENT 85 

to prescribe it. It has been given an un- 
merited penumbra of mystery, too, by 
quacks who use hyoscin as a basis for their 
"secret remedies' ' for treating drug 
habits, and who seek to camouflage their 
methods. But those who have occasion to 
use the drug frequently find no more mys- 
tery about the use of hyoscyamus prepa- 
ration than any other powerful drug. The 
very fact that this apparently dangerous 
drug is used extensively at the various 
places for treating drug addiction is sig- 
nificant. For many of these places are 
conducted by laymen who have little 
knowledge of medicine, and who frequently 
give hyoscin with an apparent recklessness 
that fills the average practitioner with 
visions of asylums and cemeteries. Yet 
this apparent "recklessness of ignorance" 
seldom results in any particularly alarm- 
ing or dangerous symptoms. And this of 
itself is practical evidence that the dangers 
from the administration of hyoscin or the 
hyoscyamus preparation have been largely 
over-estimated by the older medical 
writers. 



86 OPIATE ADDICTION 

There are occasions when these facts will 
be a source of comfort to the clinician who 
treats cases of drug addiction — the fact 
that hyoscin is not so dangerous after all, 
and that drug addicts are pretty tough and 
immune customers anyhow. 

For example, I had under my personal 
observation a patient who took the better 
part of a full tube of one-hundredth grain 
hyoscin tablets at a single dose. It was 
impossible to determine the exact number 
of tablets taken, but the nurse in charge 
declares that the tube was full of tablets, 
and the patient admits that she took all 
that were in the tube, although she thinks 
it was merely a matter of twelve or fifteen 
tablets. At any rate, she crammed as 
many tablets as she could into her hypo- 
dermic syringe and took the remainder 
orally. 

This patient was an especially robust 
woman, just beginning treatment in the 
sanitarium for the cure of her addiction. 
She had been taking two grains of morphin 
daily for several months, but had been 
addicted to the drug for several years, 



GRADUAL REDUCTION TREATMENT 87 

during which time she had attempted vari- 
ous methods of treatment without success. 
At the time of taking the hyoscin tablets 
she had had no opiate for about ten hours 
and was in a reckless frame of mind. In 
desperation she broke the lock of the med- 
icine chest and took "everything she 
found, ' ' as she expressed it. ' ' Everything ' ' 
in this instance was the tube of hyoscin 
tablets. 

The effect of this tremendous dose was 
a stupor, which was no more intense, how- 
ever, than is often produced by a one- 
fiftieth of a grain dose of the same drug, 
but which lasted about twelve hours. 
During this time her pulse rate did not 
vary much from normal and the quality 
was good. After twelve hours she re- 
gained consciousness, although for the 
next forty-eight hours she was in the 
characteristic state of mild mental con- 
fusion which is characteristic after a suf- 
ficient quantity of hyoscin has been given 
to produce delirium at all. 

After the first three hours her pupils 
became completely dilated and remained 



88 OPIATE ADDICTION 

so for a period of four weeks. As she left 
the sanitarium at the end of seven days ? 
completely cured of her addiction and in 
fine physical condition except for the 
dilated pupils, the fact that the iris muscles 
had remained paralyzed was not called to 
my attention for an additional three weeks. 
Yet, curiously enough, the patient had ex- 
perienced no very great discomfort except 
an occasional headache and an inability to 
read the newspaper. However, a solution 
of eserin dropped into the eye for three 
days restored the function of the iris com- 
pletely. 

How rapidly may the amount of opiate 
be reduced in the process of gradual re- 
duction treatment? 

It seems superfluous to say that no fixed 
rule will apply to all cases in this matter 
after what has been said about the nature 
of opiate addiction in the preceding pages. 
However, there is a certain degree of uni- 
formity in these cases, just as in the case 
of most other diseases. Some cases will 
tolerate a more rapid reduction than 
others, but in most cases it is impossible 



GRADUAL REDUCTION TREATMENT 89 

to make the rate of reduction more than 
one-quarter of a grain of morphin daily 
without producing withdrawal symptoms. 
In point of fact, it is only in exceptional 
cases that it is possible to make a uniform 
cut of this amount of morphin. And the 
rate of reduction in the case of heroin 
takers is considerably less, usually not 
more than one-eighth of a grain daily. 

In some of the States the rate of reduc- 
tion is fixed by law. Thus, in California, 
the minimum rate of reduction is the with- 
drawal of one grain of morphin weekly, 
and one-half of one grain of heroin during 
the same period. So it will be seen that 
the legal estimate in this instance, which 
is supposed to represent a fair average, is 
only about half the amount that I have sug- 
gested as possible. 

In this connection one must bear in mind 
that there is a very general misconception 
among physicians and laymen as to the 
amount of opiate that is actually necessary 
to sustain the normal balance in cases of 
addiction. At one time or another the idea 
has been promulgated that the human 



90 OPIATE ADDICTION 

body is only capable of utilizing a certain 
definite quantity of morphin, which is about 
five or six grains at the most, and any 
amount taken in excess of this quantity is 
purely superfluous. Or, stated in another 
way, if an opiate addict is taking twelve 
grains of morphin daily, about six grains 
of this is utilized to maintain his physical 
balance and the remainder is for physic 
effect. Such being the case, according to 
this theory, it is perfectly practical to 
reduce by half the daily allowance of a 
chronic addict who is taking twelve grains 
of morphin without any effect other than 
mental discomfort. So that if the drug 
habitue who is accustomed to taking 
twelve grains daily should have this 
amount cut to six grains daily without his 
knowledge of the fact he would experience 
no great discomfort, if indeed any at all. 
But this is merely theory — possibly the 
conception of some cloistered laboratory 
worker whose activities are confined 
largely to such laboratory subjects as 
guinea pigs and rabbits, and who has had 
very little practical experience with human 



GRADUAL REDUCTION TREATMENT 91 

opiate users. I suspect that this theory 
must have originated in this manner. 
Otherwise I cannot conceive how it orig- 
inated at all, for it can hardly be the con- 
ception of any practical clinician who has 
ever come closely in contact with drug 
addiction. For practical physicians know 
that, whereas one individual will get along 
comfortably for years on one grain of 
morphin daily, his neighbor may require 
ten or twelve times that amount daily 
during the same period. Moreover, if the 
patient accustomed to taking one grain 
daily has this amount suddenly decreased 
by twenty-five per cent, he will exhibit 
marked withdrawal symptoms invariably. 
And if a corresponding reduction is made 
in the case of the person who is taking ten 
times this amount he will show acute with- 
drawal symptoms just as inevitably as the 
person taking the smaller amount. It is 
not a mental condition but an actual 
physical one, which has been demonstrated 
repeatedly, and may be demonstrated at 
any time. Furthermore, it is not necessary 
to make any such great reduction as that 



92 OPIATE ADDICTION 

of twenty-five per cent, in order to make 
the demonstration. Just as positive re- 
sults will be obtained if a reduction of ten 
per cent, is made so that the patient taking 
ten grains daily is reduced suddenly to 
nine grains. The result will be just as 
positive, although the symptoms are not 
quite so violent. 

It is true, of course, that most chronic 
opiate users habitually take somewhat 
greater quantities of the drug than is 
actually required by their systems. This 
is peculiarly true at present, since the dif- 
ficulty and uncertainty in obtaining the 
drug has produced a state of apprehension 
in most of the addicts which makes them 
use the drug to excess. But opium, which 
is the most remarkable of all drugs in 
many respects, is also remarkable for the 
latitude in the amounts required to produce 
certain physiological effects, particularly 
in persons whose systems have been per- 
verted into that peculiar state which is 
exhibited in addiction. The human sys- 
tem seems to tolerate opiates with a flexi- 
bility unequaled by any other drug, and 



GRADUAL REDUCTION TREATMENT 93 

each individual system seems to have its 
own standard of toleration and require- 
ment. So that it is futile to make any un- 
iformly fixed limit which shall apply to all 
cases. 

As a matter of fact, the statutes limiting 
the amount of opiate that may be given any 
individual were enacted as legal expedi- 
ents and are used merely as a practical 
working basis. 



CHAPTER III. 
USEFUL HYPNOTICS. 



CHAPTER III. 

USEFUL HYPNOTICS. 

The bane of the narcotic addict when 
he is attempting to overcome his habit is 
insomnia. And sleeplessness, with its 
attendant discomforts, is often the most 
troublesome single element in the treat- 
ment of opiate addiction. It is in the long 
hours of sleepless nights that the patient 
suffers most from withdrawal pains and 
from mental depression. So that the ex- 
perienced patient, who has taken treat- 
ment before, frequently beseeches the 
physician to "put him to sleep" no matter 
what else may happen to him. 

"Give me a good night's sleep and I can 
get through the day all right, ' ' is the thing 
one hears repeatedly in the treatment of 
these cases. And there is much truth in 
the statement. A very great majority of 
patients are able to get through the day 

97 



98 OPIATE ADDICTION 

in very good condition if they are given 
a good night's sleep. Yet the insomnia 
that usually attends any form of treat- 
ment is often most difficult to overcome. 

The advent of a group of new hypnotics 
in recent years has helped to simplify the 
problem of insomnia immensely. Until re- 
cently about the only hypnotic available 
was chloral hydrate, and the combination 
of this hypnotic with some of the bromides. 
And even now there are cases in which 
good full doses of chloral, either alone or 
in combination, will prove effective when 
other measures have failed. In most cases, 
however, chloral is not the hypnotic of 
choice. 

One of the most useful and least harm- 
ful hypnotics, particularly when quick 
action is desired, is dial-ciba. This hyp- 
notic given in about three grain doses dis- 
solved in hot water and taken hot, is quick 
acting and very effective. Its action is not 
so prolonged as such a hypnotic as sul- 
phonal, for example, but the dose may be 
repeated often and apparently without any 
ill effects. It may be used, also, as a mild 



USEFUL HYPNOTICS 99 

sedative to steady the patient's nervous 
system during the daytime in some cases. 
But its best effects are as a hypnotic, and 
as such it has no superior, in my opinion, 
when quick and certain action is desired. 

Very closely similar in its action to dial- 
ciba, and equally free from bad effects 
when given in reasonable dosage, is 
medinaL Five grain doses, repeated in an 
hour when necessary, are very effective. 
And medinal has the very great advantage 
that it may be administered hypodermic- 
ally, the five grain tablets dissolving read- 
ily in twenty-five or thirty minims of hot 
water. There are many occasions, particu- 
larly toward the end of the treatment, 
when a hypodermic of medinal will pro- 
duce very gratifying results, as it may be 
substituted for the expected dose of nar- 
cotic. The very fact that it is given hypo- 
dermically has a helpful psychic effect 
upon the patient, in addition to the more 
tangible one of producing gratifying 
sleep. 

Thus medinal is often a very valuable 
adjunct in the treatment of opiate with- 



100 OPIATE ADDICTION 

drawal. In this connection, it should be 
borne in mind that it is only recently that 
the medinal tablets have been so made that 
they will dissolve completely in a few 
drops of hot water. The older tablets could 
be used in this manner, it is true, but were 
not so readily and completely soluble. All 
the tablets dispensed at the present time, 
however, dissolve very readily. 

One of the most satisfactory all-around 
hypnotics in the treatment of these cases 
is sulphonal given in fifteen or twenty 
grain doses, because its hypnotic effect is 
much more prolonged than that of dial- 
ciba or medinal. As its action is not very 
rapid, it is often expedient to combine it 
with one of the other hypnotics. Fre- 
quently a tablet of dial-ciba dissolved in 
hot water, or a five grain medinal tablet 
given hypodermically at the same time that 
fifteen grains of sulphonal are adminis- 
tered, will give the patient five or six hours 
of refreshing sleep. And even when the 
patient wakens, the action of the sulphonal 
is often still prolonged to such an extent 
that there is not acute craving for an opiate 



USEFUL HYPNOTICS 101 

immediately after awakening, as is often 
the case otherwise. 

One of the standard hypnotics which 
acts very satisfactorily in many cases 
is veronal, and its soluble salt, veronal 
sodium. Veronal sodium is supposed to be 
identical with medinal; and certainly the 
therapeutic action of the two appears to 
be very similar. Nevertheless, medinal 
seems to be more readily soluble than 
veronal sodium and, in my experience, is 
superior for hypodermic use. Otherwise 
there seems to be little to choose between 
the two. 

Veronal, which is very effective, is prac- 
tically insoluble except in large quantities 
of fluid. But when given in full doses it 
occasionally produces tremors, ataxia, and 
hallucinations, and seems to be peculiarly 
likely to produce these effects in narcotic 
cases. The peculiar delirium produced by 
this drug is sometimes very persistent and 
difficult to control, and for this reason some 
of the other hypnotics are usually prefer- 
able in the treatment of most cases of 
opiate addiction. 



102 OPIATE ADDICTION 

In some cases of insomnia small doses of 
luminal, or luminal sodium, are very effec- 
tive and most satisfactory. Luminal 
sodium is very soluble and may be given 
hypodermically in two or three grain 
doses. Apparently it has no tendency to 
produce mental confusion and has no effect 
upon the respiration or circulation. But 
occasionally it does produce ataxia, a 
"luminal jag," which may persist for 
several days. In this condition the patient 
staggers about, but without other unpleas- 
ant symptoms, and frequently he himself 
does not realize that his gait is unsteady. 
In some cases the upper extremities seem 
to be affected so that the patient is unable 
to manipulate small articles such as a 
spoon. I have observed this in only two 
cases, however, both of them women of the 
neurotic type, so that I am by no means 
sure that the luminal was entirely respon- 
sible for the condition. But there seems 
to be no doubt that large doses of the drug 
sometimes produce ataxia with the char- 
acteristic unsteadiness of gait. 

Now and again one sees a case of stub- 



USEFUL HYPNOTICS 103 

born insomnia in which paraldehyd works 
effectively when everything else has failed. 
Such cases are likely to be the nervous 
type of headstrong women with the hys- 
terical element rather pronounced. And 
in such cases, particularly after the stage 
of active treatment has passed, paralde- 
hyd is often useful. The same type of 
cases that are likely to be benefited by the 
vile smelling valerian preparations, or 
asafoetida, are the ones most likely to be 
helped by the evil smelling and tasting par- 
aldehyd. In such cases the drug should 
be administered in at least one drachm 
doses, and the psychological effect is en- 
hanced if it is given with no attempt to dis- 
guise its taste or smell. Possibly it is the 
disciplinary effect of the bad odor and taste 
that helps so materially in these cases. In 
any event, paraldehyd is sometimes useful 
as a hypnotic, but it should not be used 
from preference in the early stages of 
treatment because of its possible action 
upon the respiratory centers. 

One should always bear in mind that in 
suitable cases the time-honored chloral 



104 OPIATE ADDICTION 

hydrate is an effective and useful hypnotic. 
But here again one must be governed by 
the physical condition of the patient. It 
is well to remember that during the active 
stage of treatment for overcoming the 
addiction there is likely to be a lowering 
of the arterial pressure and, as chloral acts 
as a depressant to the vasomotor centers, 
it should not be given in cases where the 
blood pressure is not up to normal. One 
should use this drug, then, with an eye on 
the blood pressure. Which means that 
usually it should not be given during the 
early stages of active treatment but should 
be reserved to combat the insomnia that 
often persists as an aftermath to almost 
any form of treatment. 

One of the milder hypnotics, which is 
also useful as a nervous sedative, is chlore- 
tone. It is true that the hypnotic action 
of this drug is not very pronounced in most 
cases, but when there is nausea and vomit- 
ing, as frequently happens in the early 
stages of active treatment, chloretone, 
either alone or in combination, is often 
very useful. As a rule, it is better to give 



USEFUL HYPNOTICS 105 

it in capsules, but in cases of nausea it 
sometimes acts effectively when dissolved 
in a little brandy and poured over cracked 
ice. Five grain doses administered every 
hour for four or five doses will often prove 
efficacious. 

Chloretone in combination with anti- 
pyrin is also useful at times in controlling 
the nervousness and "leg pains'' that 
often follow active withdrawal treatment. 
It should be given in the combination of 
five grain doses of each drug dispensed in 
capsules. The mixture results in liquefac- 
tion, but this does not in any way interfere 
with the therapeutic action. 

In addition to the various hypnotics that 
have been referred to here there are a 
number of preparations on the market, 
such as combination of the various chlor- 
als, which are very useful. However, gen- 
erally speaking, the hypnotic of choice 
should be the one that the physician is 
accustomed to giving and with which he is 
most familiar. For with hypnotics, as 
with firearms, the best is the one with 
which we are most familiar. Just as the 



106 OPIATE ADDICTION 

hunter does not select a new type of fire- 
arm to experiment with in hunting big 
game, so the clinician had best not experi- 
ment with new hypnotics in treating the 
insomnia of opiate withdrawal. In these 
cases one needs a familiar as well as a 
powerful weapon rather more than for any 
other type of sleeplessness. 



CHAPTEE IV. 
EAPID WITHDRAWAL METHODS. 



CHAPTER IV. 

EAPID WITHDEAWAL METHODS. 

There is no royal road to recovery 
from opiate addiction. Nevertheless, some 
highways are much less rough and rocky 
than others, and, given ideal conditions, 
the skillful physician is often able to steer 
his patient clear of the rougher places and 
enable him to make the journey back to 
normal health quickly and with a minimum 
of discomfort. 

To accomplish this, several important 
elements are necessary, the most import- 
ant, of course, being the skill and experi- 
ence of the physician himself. But almost 
as important, if indeed not equally so, is 
the intelligence, skill, and experience of the 
nurse in charge of the case. It is true that 
the physician may sometimes get on fairly 
well with an intelligent nurse who has had 
no actual experience in treating these cases 

109 



110 OPIATE ADDICTION 

by giving minute instructions and a great 
deal of personal attention. But even so, 
it is a dubious experiment, and one that 
should not be attempted from choice. 
Many failures in treatment may be attrib- 
uted to lack of experience on the part of 
the nurse. 

It is proverbial that nurses that have 
had no practical experience in dealing with 
mental cases are frequently worse than 
useless. And this is true even in a greater 
degree in the treatment of the opiate 
addict. For one thing, the opiate addict 
is the most sophisticated of all patients. 
Also, he is the most critical. He not only 
has a great amount of knowledge about 
addiction in general, but, in addition, he 
usually has quite an array of pet "whims' ' 
in connection with his own particular case. 
Add to this combination the apprehension 
that the patient always feels about under- 
going treatment, and we have a situation 
quite beyond the range of novices. 

It will not take long for the addict who 
is under treatment to discover that he is 
in inexperienced hands. And when he does 



RAPID WITHDRAWAL METHODS 111 

so he is likely to become panicky and dif- 
ficult to manage. His confidence in his 
physician may offset in a measure his dis- 
trust of the inexperienced nurse, but this 
throws an extra burden on the physician 
and lessens his chance of successful treat- 
ment. And if by any chance the physician 
as well as the nurse is inexperienced in 
the practical handling of this class of 
cases, it will only be by the greatest 
"luck," or the interposition of that in- 
tangible force which the more reverent per- 
sons refer to as Providential, if the treat- 
ment is carried to a successful termination. 

In short, it is impossible to overempha- 
size the importance of experience in the 
treatment of these cases. And this applies 
to every case regardless of the particular 
form of treatment. The fact of having a 
vast amount of knowledge about general 
medicine or general nursing methods will 
not compensate for the lack of special 
knowledge which is acquired only by actual 
contact and experience. 

It is this special knowledge that is re- 
sponsible for the reputation acquired by 



112 OPIATE ADDICTION 

various institutions for treating opiate ad- 
dictions scattered throughout the country. 
Wherefore the inexperienced physician 
will do well to select one of these institu- 
tions for carrying out his treatment. For 
in such institutions he is sure to have the 
benefit of experienced nursing; and, if he 
is wise, he will not be oblivious to the 
casual suggestions of the nursing staff that 
are sure to be dropped from time to time ; 
or too dictatorial and inflexible in his atti- 
tude. He will do well to give the attending 
nurse considerable latitude in handling 
perplexing situations as they arise — and 
almost invariably they do arise in every 
case — and garner useful knowledge for 
future reference from these little un- 
charted incidents. 

And in this connection one should bear 
in mind that the proper place for treating 
opiate addiction is in a hospital or in some 
similar institution. It is possible, of 
course, under favorable circumstances, and 
with the aid of competent nursing, to treat 
the patient successfully in his home, but 
this is true only in exceptional cases. And 



RAPID WITHDRAWAL METHODS 113 

even under the most favorable circum- 
stances treatment at home is seldom advis- 
able. If for no other reason, the mental 
reaction to familiar surroundings is not 
helpful to the patient and may be positively 
harmful. Familiar sights and familiar 
sounds are far more likely to be harmful 
than helpful to the patient undergoing 
treatment. And one should not disregard 
the significance of the fact that the physi- 
cians who have had the greatest experience 
in treating these cases are the ones most 
loath to attempt any form of treatment at 
the patient's home. 

In surgery the measure of success is not 
dependent solely upon the technical oper- 
ative skill of the surgeon but upon his 
knowledge and judgment about his 
patient's condition in determining the time 
for operation. It is this combined knowl- 
edge of when to operate and how to oper- 
ate that determines the status of the suc- 
cessful surgeon. In other words, it is 
knowledge and judgment as well as skill 
that determines the final issue. 

The successful treatment of drug addic- 



114 OPIATE ADDICTION 

tion is dependent upon these same rules. 
And the particular form of treatment given 
is frequently much less important than the 
time of giving such treatment. No form 
of treatment will be uniformly successful, 
or attain a creditable percentage of suc- 
cesses, that is given indiscriminately to 
every patient who presents himself for 
treatment and without preliminary prepa- 
ration. It is just as essential to get the 
patient into the proper mental and phys- 
ical condition before attempting final 
treatment to cure his addiction disease as 
it is to properly prepare a patient for a 
surgical operation. 

There are "emergency cases, " of 
course, in which for one reason or another 
it is sometimes necessary to give drastic 
treatment immediately, just as there are 
emergency cases in surgery. And some of 
these cases prove to be eminently success- 
ful just as in the case of surgical emergen- 
cies. But these cases are the exception 
and may be practically disregarded in a 
general consideration of the subject. 

It seems hardly necessary to say that 



RAPID WITHDRAWAL METHODS 115 

most cases presenting themselves are not 
in condition for immediate treatment. In 
most instances the patient is taking a quan- 
tity of the drug greatly in excess of his 
bodily requirement, and with the inevit- 
able metabolic disturbances. Usually there 
is constipation with a marked tendency to 
acidosis, and frequently with intercurrent 
diseases that are aggravated by the gen- 
eral systemic disturbance. 

Of course, these conditions are not 
always the result of an excessive quantity 
of the drug, but frequently the reverse, or 
an irregularity in the amount taken. This 
is particularly the case at present on ac- 
count of the difficulty in obtaining the drug 
and the extortionate prices. And usually 
this disturbance of the patient's organic 
mechanism is aggravated by a distressed 
mental condition. So that the first prob- 
lem of the physician is to reestablish 
normal bodily functions as nearly as pos- 
sible and to fortify the patient's mental 
attitude. 

I am assuming, of course, that the 
patient under consideration is honestly 



116 OPIATE ADDICTION 

desirous of being cured of his habit. 
Otherwise any treatment will be futile. 
But in the sincere class of patients it is 
frequently possible to improve their gen- 
eral condition with astonishing rapidity 
merely by regulating the dosage of mor- 
phin and establishing their confidence. 
And in almost all of these cases the estab- 
lishment of the normal metabolic processes 
may be hastened by the administration of 
some of the mixed endocrine preparations 
and by stimulating elimination. 

If it is possible to have the patient in 
the hospital during this course of prepara- 
tion it is much easier to reduce the dosage 
of morphin rapidly so that when the final 
treatment begins he will be taking a com- 
paratively small amount of the drug. 
Meanwhile it is much easier to get the 
bodily functions into good working order 
in hospital surroundings and under super- 
vision. 

In deciding upon the kind of final treat- 
ment to be given in any particular case 
one should take into consideration the in- 
telligence and temperament of the patient, 



RAPID WITHDRAWAL METHODS 117 

his emotional stability or instability, and 
the measure of his earnestness to be cured. 
Also the amount of the drug he is taking. 
For, although it is true that patients who 
are taking tremendous quantities of the 
drug sometimes respond very readily to 
treatment, while others who are taking 
only very small quantities are most difficult 
to handle, this is not the rule, I believe, and 
these anomalies may be explained by the 
temperamental differences in the patient, 
or the surrounding conditions, rather than 
by any difference in the quantity of the 
drug. For it appears to be true that, 
everything else being equal, it is easier to 
treat the patient that is taking a small 
quantity of the drug than one who is taking 
large quantities. Moreover, the method 
of treatment may be greatly simplified in 
cases taking small quantities of the drug. 
Drastic treatment in such cases is seldom 
advisable or necessary. 

Thus, if the patient who has been pre- 
pared for treatment is taking only one 
grain of morphin daily it is usually advis- 
able to try some simple form of treatment 



118 OPIATE ADDICTION 

at first, reserving the more heroic methods 
if the other proves ineffective. For ex- 
ample, such a patient may be given a 
rather brisk laxative at bedtime after 
having a prolonged neutral bath, followed 
by his usual dose of narcotic. The follow- 
ing morning he should be given some 
saline, such as the sulphate of magnesia, 
so as to insure a thorough evacuation of 
the bowels. Half an hour later he may be 
given fifteen or twenty grains of sodium 
bromid and about fifteen grains of sul- 
phonal. The bromid may be given in a 
solution in one of the various digestive 
mixtures, particularly if there is any 
tendency to gastric disturbance. Also it 
is a good routine practice to give these 
patients a sufficient quantity of sodium 
bicarbonate daily to correct the tendency 
to acidosis which is almost always present. 
As soon as the patient begins to show 
withdrawal symptoms, as he will within 
two or three hours, he may be placed in a 
hot bath with an ice bag to the head, for 
ten or fifteen minutes, or placed in a pack 
to promote perspiration, then cooled off 



RAPID WITHDRAWAL METHODS 119 

slowly and given a salt glow. This will 
usually relieve his acute symptoms so that 
he will be fairly comfortable, and he will 
often drop into a sound sleep which may 
last several hours. And when he awakes 
and becomes restless, the hot bath, or 
sweating process can be repeated several 
times during the twenty-four hours. Mean- 
while he is urged to take as much liquids or 
light nourishment in as great quantities as 
possible. 

The dose of sodium may be repeated in 
the middle of the day if there is much ner- 
vousness, and should be again given in the 
evening with the addition of the sulphonal. 
And if the insomnia is troublesome it may 
be advisable to give one or another of the 
other hypnotics in addition to the sul- 
phonal during the night. The bath and 
packs, and massage, help to relieve the dis- 
comfort and sometimes do so completely. 
And in such cases they should be repeated 
as often as necessary to keep the patient 
reasonably comfortable. 

When there is a tendency to weakness 
or unsteadiness of the heart some reliable 



120 OPIATE ADDICTION 

preparation of digitalis given hypoder- 
mically is usually most satisfactory. Digi- 
talis is usually preferable to strychnin in 
these cases because strychnia tends to ex- 
aggerate the nervousness and muscular 
twitching, which are likely to be very 
troublesome in any event. Spartein in 
heroic doses is highly recommended by 
some observers as it also tends to mitigate 
the pain in some cases. My own observa- 
tions of this drug, however, indicated that 
its action in relieving the pain is very 
slight and, on the whole, not dependable. 

The treatment just outlined will prove* 
satisfactory and effective without other 
medication in a limited number of cases if 
given for forty-eight to sixty hours. Even 
in the most favorable cases, however, it is 
usually advisable to continue with the bro- 
mides during the day and some hypnotic at 
night for several days longer to combat 
the depression and general nervousness. 
And there are cases in which the leg pains 
persist for a week to ten days. Yet, there 
is likely to be a very strong psychic ele- 
ment in such cases. 



KAPID WITHDRAWAL METHODS 121 

In the treatment just outlined all nar- 
cotics are cut off at once. But the number 
of cases in which it is advisable or possible 
to do this is limited. And there seems to be 
no particular advantage in allowing the pa- 
tient to suffer unduly when an occasional 
small dose of some narcotic will tide him 
over a distressing period without inter- 
fering with the progress of the treatment. 
For this purpose, however, there appears 
to Be a very distinct choice of narcotics. 
And it is a good working rule, when it is 
found necessary to give a narcotic at all, 
not to give the particular one that the 
patient has been accustomed to taking. 
For example, if he is addicted to morphin, 
it is usually possible to relieve the acute- 
ness of his symptoms with relatively small 
doses of codein or dionin, preferably the 
latter. And, as neither of these drugs are 
habit forming in any such degree as mor- 
phin or heroin, there is little difficulty in 
cutting them off immediately after the 
acute withdrawal symptoms have subsided. 
Dionin seems to be about twice as powerful 
as codein, that is, it will accomplish the 



122 OPIATE ADDICTION 

same purpose and usually somewhat better 
in half the dosage of codein. 

There are occasions, however, when 
neither of these drugs, even when admin- 
istered in large doses, will produce the 
desired effect. And in such cases the addi- 
tion of a minute quantity of heroin com- 
bined with either dionin or codein some- 
times works like magic. Frequently a 
single dose of heroin given in this manner 
suffices and will not have to be repeated 
during the remainder of the treatment. 

It is in determining just when to give 
these occasional doses of narcotic that ex- 
perienced nursing is important. There can 
be no fixed rule in this matter, which 
should be entirely dependent upon the good 
judgment of the person in attendance. 

There seems to be no advantage in let- 
ting the patient suffer when a small amount 
of narcotic will give relief without inter- 
fering with the progress of the treatment. 
The mediaeval idea that "suffering is good 
for a man" — that something will be gained 
by allowing the person to suffer unneces- 
sarily — has no place in the successful 



RAPID WITHDRAWAL METHODS 123 

treatment of opiate addiction. It is remin- 
iscent of our hard-headed, puritanical an- 
cestors whose joyous conception of life 
seems to have been a prolonged period of 
purification-suffering on earth with rather 
more than even chances of intense caloric 
purification hereafter. And this concep- 
tion is the direct ancestor of the false idea, 
which still prevails in some quarters, that 
if the patient is made to suffer during the 
course of treatment to cure him of his 
addiction this suffering will act as a deter- 
rent in preventing him again becoming 
addicted to opiates. But this is a false 
conception. Indeed, it seems to be a clearly 
established fact that the patients subjected 
to the harsher methods of treatment, such 
as locking them up and letting them ' ' suf- 
fer it out," are the very ones who most 
readily go back to the habit. 

The dominant idea in modern medicine, 
the one thing that has made possible the 
advances in medicine as well as surgery, 
is the elimination of pain by any method 
that does not interfere with the progress 
of recovery. And this applies just as cer- 



124 OPIATE ADDICTION 

tainly in the treatment of opiate addiction 
as in any other branch of therapy. Thus 
the various methods that have been de- 
vised in recent years for treating opiate 
addiction are all designed to mitigate the 
patient's suffering during the course of 
withdrawal. At least three of these treat- 
ments are worthy of consideration as prac- 
tical and legitimate methods that are used 
successfully at the present time. 

THE LAMBEKT-TOWNS METHOD OF DBTJG 
WITHDKAWAL. 

In the beginning of the treatment the 
patient is given five compound cathartic 
pills and five grains of blue mass. If these 
fail to act in six hours, he is given a saline 
cathartic sufficient to produce three or four 
free movements. Following this he is given 
two-thirds or three-fourths of his total 
twenty-four hour morphin or opium dose 
in three divided doses at half -hour inter- 
vals, preferably in the way he has been ac- 
customed to taking it. Usually it is not 
necessary to give more than two doses of 
morphin, because at the time of giving the 



RAPID WITHDRAWAL METHODS 125 

first dose the patient is also given six drops 
of the following mixture : 

Gm. or C.c. 

Tincturae belladonnse (15 per cent) 60 

Fluidextracti xanthoxyli 

Fluidextracti hyoscyami aa 30 

These drops are measured from a medi- 
cine dropper and preferably in capsules to 
avoid the disagreeable taste. This hyos- 
cyamus mixture is given every hour, day 
and night, continuously throughout the 
treatment, increasing two drops every six 
hours until the dose has reached 16 drops. 
If the patient develops symptoms of bella- 
donna poisoning at any time, which is 
shown by dilated pupils, flushed face, dry 
throat, or a "peculiar incisive and insistent 
voice and an insistence on one or two 
ideas," the drops should be discontinued 
for a few doses. Dilated pupils and a 
certain amount of dryness of the throat 
are present early in most cases, of course, 
but not to the extent to indicate poison- 
ing. 

If the hyoscyamus mixture has been 
stopped, it is again begun at a reduced 
dosage as soon as the symptoms have sub- 



126 OPIATE ADDICTION 

sided. And if the patient has an idiosyn- 
crasy against belladonna (which is rather 
rare), it will be shown in the first six or 
eight hours. In that event the treatment 
is given in diminished dosage. On the 
other hand, when 16 drops, the full dose, 
given for twelve consecutive hours does 
not cause dryness of the throat, this should 
be increased to 18, or even 20 drops per 
hour, and continued unless there is dryness 
of the throat. 

In combination with this hourly bella- 
donna-mixture treatment, the patient is 
again given five compound cathartic pills 
and five grains of blue mass ten hours 
after the first dose of morphin. If the 
bowels do not act in eight hours, a saline 
cathartic should be given. When the 
bowels have acted thoroughly, one-half of 
the dose of morphin given at first should 
be given; and ten hours after the second 
dose of morphin, that is, about the twenty- 
eighth hour of the treatment, five more 
compound cathartic pills and five grains of 
blue mass are given, followed again by 



RAPID WITHDRAWAL. METHODS 127 

a saline if the bowels do not act in eight 
hours. After the bowels have acted 
thoroughly, the third dose of morphin is 
given, which should be one-sixth of the 
first dose, and usually this is the last dose 
of morphin required. 

At about the forty-sixth hour of the 
treatment, that is, ten hours after the last 
dose of morphin, five compound cathartic 
pills and five grains of blue mass are again 
given, followed by a saline if needed. 
About this time the characteristic "bilious 
green stool" should appear. And when 
this occurs, two ounces of castor oil are 
given to clean out the intestines. Should 
this fail to appear as scheduled, it may be 
necessary to continue the belladonna mix- 
ture over one or two more "cathartic 
periods" before giving the oil. 

It is during this last bowel-moving 
period that most patients suffer their 
greatest discomfort and are likely to be- 
come extremely nervous. But this may be 
controlled by codein, "which can be given 
hypodermically in five grain doses and re- 



128 OPIATE ADDICTION 

peated, if necessary; or some form of 
valerianates may help them." 

Beginning about the middle period of 
the treatment it is usually advisable to 
stimulate the patient with strychnin or 
digitalis, or both. The intervals of admin- 
istration should be left entirely to the 
judgment of the attending physician. 

THE PETTEY METHOD OF DRUG WITHDRAWAL. 

In this treatment, which was devised by 
Dr. George E. Pettey, the patient is urged 
to drink large amounts of water to dilute 
the body fluids, and to cause watery move- 
ments and a large amount of urine, and is 
given active cathartics, and tub and vapor 
baths. 

Pettey 's medicinal treatment is scopo- 
lamin in 1/200 grain doses, spartein sul- 
phate in two-grain doses, and 20 grains of 
sodium thiosulphate every two hours for 
24 hours. 

On the first day of the treatment the 
patient is given his usual dose of morphin, 
but has no food either at noon or at supper 
time. 



RAPID WITHDRAWAL METHODS 129 

Pettey's cathartic prescription is as fol- 
lows : 

3 Calomel 

Powdered extract cascara 

Sagrada aa gr. x 

Ipecac gr. i 

Strychnin nitrate gr. % 

Atropin sulphate gr. 1/50 

Mis. and make 4 capsules. 

The patient takes one of these capsules 
every two hours, beginning at 4 P. M. The 
following morning he receives no nourish- 
ment and no morphin until his bowels have 
moved, but about 5 A. M. the next morning 
he is given one-twentieth grain of strych- 
nin hypodermically. Half an hour later he 
is given two ounces of castor oil or the 
contents of a bottle of magnesium citrate. 
And the strychnin and the oil or saline are 
repeated every two hours until there is a 
thorough bowel evacuation, and in the 
meantime no morphin should be given. 

As soon as the bowels have moved freely 
the patient should be given from one-half 
to two-thirds of his usual dose of morphin 
at the same intervals at which he has been 
accustomed to take the drug. And he may 
eat as much as he pleases until about six 



130 OPIATE ADDICTION 

hours before he begins his second purga- 
tive treatment, which should begin at the 
end of forty-eight hours from the first. 
This purgative treatment should be given 
in the same way on the first day, and the 
morphin is continued in doses just sufficient 
to keep the patient comfortable, until the 
last dose of the cathartic capsule has been 
given. Then the opiate is stopped, and no 
more given thereafter. 

From six to eight hours after the second 
purgative course has been completed, the 
strychnin hypodermically and the oil or 
saline should be repeated, as before. But 
following this, as soon as the patient feels 
the need of the morphin, instead of mor- 
phin or an opiate, he is given 1/200 grain 
of scopolamin hypodermically. This is re- 
peated in thirty minutes if there is much 
discomfort. And if the patient does not 
sleep, a third dose may be given in half 
an hour, and the amount increased if neces- 
sary to produce the desired effect. The 
effect aimed at is either sleep or mild in- 
toxication, in which case the patient does 



RAPID WITHDRAWAL METHODS 131 

not suffer. As soon as he wakes, or as soon 
as the intoxication begins to subside, he is 
given another 1/200 grain of scopolamin, 
and in this way the intoxication is pro- 
longed, thus keeping the patient free from 
pain, for from thirty-six to forty-eight 
hours. The scopolamin should then be 
stopped. 

During this scopolamin treatment and 
for twenty-four hours afterward, Pettey 
gives 20-grain doses of sodium thiosul- 
phate every two hours, which he thinks 
supplements the effect of the calomel pur- 
gative. And during the treatment Pettey 
corrects any tendency to weaken circula- 
tion by giving spartein sulphate in doses 
of two grains, every four to six hours. 

The whole course of treatment lasts 
from five to six days, followed by treat- 
ment aimed at improving the patient's gen- 
eral condition. 

THE SCELETH METHOD OF DRUG WITHDRAWAL. 

. The basis of Sceleth's medical treatment 
is the following prescription : 



132 OPIATE ADDICTION 

Scopolamin hydrobromid gr. 1/100 

Pilocarpin hydrobromate gr. 1/12 

Ethyl-morphin hydrochlorid (dionin) gr. ss 

Fluid extract cascara sagrada ttjj xv 

AlCOhol TT£ xxxv 

Water q.s. ad 3 i 

The patient under treatment is first 
given a saline cathartic, and then the above 
mixture of scopolamin (or hyoscin), pilo- 
carpin, ethyl-morphin hydrochlorid, and 
cascara sagrada, the dosage determined by 
the amount of morphin the patient is 
taking. Thus, if more than 10 grains of 
morphin per day are being taken, 60 
minims are given every three hours, day 
and night, for six days. Patients who are 
taking less than 10 grains of morphin a 
day start with a dose of 30 minims of the 
mixture; and if less than 5 grains, 15 
minims. On the seventh day the dose is 
reduced to 30 minims; on the eighth day 
15 minims; and on the ninth day 15 
minims three times a day, instead of every 
three hours day and night. This treat- 
ment is discontinued on the tenth day and 
strychnin nitrate, one-thirtieth grain three 
times a day, is substituted. The following 
day the strychnin is reduced to one-six- 



KAPID WITHDRAWAL METHODS 133 

tieth grain three times a day, and this is 
continued for a week. 

During the first five days of the treat- 
ment Sceleth gives a very light diet, but 
encourages the taking of liquids freely. 
This applies to all cases. 

During the first three days of the treat- 
ment the patients are usually sleepless, 
and frequently nauseated, as should be ex- 
pected. The guiding indicator, however, 
is the pulse-rate. Thus, if the pulse falls 
below 40 or goes above 120 per minute, the 
scopolamin mixture is stopped tempo- 
rarily. And should there be any signs of 
collapse, one-half grain of ethyl-morphin 
hydrochlorid, or one-quarter grain of mor- 
phin should be given hypodermically. In 
some cases, particularly of old morphin 
takers, small doses of heroin work like 
magic. In about 4 per cent, of the cases, 
according to Sceleth, there is scopolamin 
delirium, sometimes rather severe. In such 
cases the scopolamin may be omitted from 
the mixture for a few doses, and then 
added in small amounts. These are simply 
incidents in the course of treatment, how- 



134 OPIATE ADDICTION 

ever, and need not interfere with its suc- 
cessful termination. 

One objection to this treatment is that 
it is rather "long drawn out" as compared 
with some others. Nevertheless, it is the- 
oretically at least, a very rational one. For 
it "represents the substitution of ethyl- 
morphin hydrochlorid for morphin; the 
fighting of the morphin depression by sco- 
polamin ; the necessary promotion of secre- 
tions by pilocarpin, and the necessary laxa- 
tive treatment by cascara." 

BISHOP *S PRINCIPLES OF TREATMENT IN RAPID 
WITHDRAWAL. 

Bishop follows no routine in his with- 
drawal of opiate. He does, however, advo- 
cate as rapid a withdrawal as possible once 
the withdrawal is undertaken. He uses 
without particular formula or special com- 
binations the drugs adapted to the current 
clinical requirements of the individual 
case, apparently taking from any method 
and from his own experience whatever is 
applicable to the needs of that case at any 
given time. 



RAPID WITHDRAWAL METHODS 135 

He regards hyoscin or scopolamin as 
functioning solely as an anaesthetic or 
amnesic or nervous system controller 
during a period of withdrawal of short 
duration, in which the patient is treated 
symptomatically by support to circulation 
and increased elimination, quiet and rest, 
and other medication or therapeutic atten- 
tion as indicated. He does not regard 
hyoscin or scopolamin or other anaes- 
thetic or amnesia producing medication as 
of specific action against addiction itself. 

He uses smaller doses of hyoscin or 
scopolamin or other medication of similar 
effect than do many others, and explains 
the efficacy of the smaller doses as being a 
result of thoroughness in the stage of 
preparation and preliminary elimination 
and circulatory and endocrine and other 
readjustment and removal of complicating 
conditions and elements. Thereby he 
secures a more normal reaction to all medi- 
cation employed during withdrawal. 

His attitude towards eliminants is that 
the addict should not be over-purged, as 
this exhausts true elimination and may 



136 OPIATE ADDICTION 

produce a mucous colitis, to which he and 
others attribute failure in some cases. He 
states that the addict in normal balance 
and functional tone requires no more 
drastic catharsis than the average man, 
and that extra intestinal motility and 
evacuation can be secured by peristaltic 
stimulators as indicated. 

He believes that by careful preparatory 
treatment and securing of approximate 
normality of function and psychology be- 
fore withdrawal of opiate, and then with- 
drawing opiate as rapidly as possible and 
maintaining functional balance and avoid- 
ing shock or strain or exhaustion or undue 
suffering during withdrawal, the pro- 
longed strain and readjustments of the 
period of what is called " after care" so 
emphasized by most, can be vastly short- 
ened or avoided. 

Bishop regards these persisting and pro- 
longed manifestations of the usual " after 
care" period as extremely difficult of en- 
durance for the patient, even worse in 
some ways than the actual withdrawal suf- 
ferings. He also regards them as being 



RAPID WITHDRAWAL METHODS 137 

not so much sequelae of cure as more often 
in reality results or indications of uncured 
or incompletely cured addiction itself due 
to persisting low grade activity of the ad- 
diction mechanism. He also regards them 
as of greatest importance, and as deter- 
mining in many cases the ultimate prog- 
nosis as to relapse, and as importantly 
influencing the subsequent mental, nervous 
and physical well-being of the patient. 

He is guided by the clinical indications 
of symptoms and reactions of the addic- 
tion itself and of the patient, both in his 
selection of time for withdrawal and in 
selections of method of withdrawal and 
conduct of its course. It seems that in 
this way he largely avoids or greatly 
lessens the prolonged and dangerous man- 
ifestations of " after care," which he calls 
" post- withdrawal" symptoms. 

To follow his teaching of course neces- 
sitates more education and clinical teach- 
ing of the average physician in the subject 
of addiction than is at present available, 
but it seems probable that the future clin- 
ical and therapeutic development of addic- 



138 OPIATE ADDICTION 

tion treatment will be along the lines sug- 
gested by him, and possibly in discoveries 
along the lines of some of the as yet 
unsolved problems of biochemistry and 
serological research in opiate addiction. 

It will be observed that the basis of all 
these treatments for drug withdrawal is 
the administration of some preparation of 
hyoscyamus and the establishment of good 
elimination. In actual practice there 
seems to be no special advantage in pro- 
ducing elimination to the extent of violent 
purging, as this is distinctly weakening 
and still further depletes the already 
weakened condition of the patient. Ordi- 
nary elimination produced by mild laxa- 
tives is preferable in all cases regardless 
of the particular method employed in the 
withdrawal treatment. Moreover, it seems 
to make very little difference what par- 
ticular form of laxative is used if a 
thorough bowel evacuation is produced. 
And since almost every physician has his 
own pet laxative mixture with the dosage 
of which he is most familiar, I believe it 
is better for each physician to use his 



RAPID WITHDRAWAL METHODS 139 

particular laxative until the desired effect 
is produced rather than attempt some un- 
familiar mixture. Compound cathartic 
pills, cascara, phenolphthalein — any of 
these appear to be effective, particularly 
when assisted by some saline mixture given 
the following morning. 

As regards the various preparations of 
hyoscyamus, there seems to be no differ- 
ence whatever in the effect produced by 
scopolamin and hyoscin. One may use 
these substances interchangeably in the 
same case without any apparent difference 
in action. 

The essential thing in using hyoscin for 
treating these cases is to keep the patient 
in a state of mild hyoscin delirium for a 
period of about thirty-six to forty-eight 
hours. At the same time it is advanta- 
geous to add pilocarpin to promote the 
secretions which are retarded by the hy- 
oscin. This in effect is an abbreviated 
combination of the methods suggested by 
Pettey and Sceleth. 

For some reason or other an air of mys- 
tery has been thrown around the so-called 



140 OPIATE ADDICTION 

hyoscin treatment, largely, I believe, be- 
cause hyoscin forms the basis of the 
" cures" in the various institutions not 
conducted by regular physicians. Fre- 
quently their treatment is very successful 
and usually it is very simple. But natu- 
rally they wish to keep their methods 
secret, and convey the impression that it 
requires special knowledge and great skill 
to handle addiction cases successfully. 
And the fact that most physicians know 
very little about the treatment of drug 
addiction and have few occasions for 
using hyoscin in their practice, has fos- 
tered this attitude of the quack. 

Now, in point of fact there is nothing 
very fearsome, or mysterious, or compli- 
cated in treating opiate addiction with 
some hyoscin combination. The crux of 
the whole thing is simply to put the patient 
into a mild state of hyoscin delirium and 
keep him in that condition for about 
thirty-six to sixty hours, meanwhile using 
ordinary medical judgment in treating 
symptoms as they arise. 

It is simply the part of universal med- 



RAPID WITHDRAWAL METHODS 141 

ical wisdom to have the patient in as good 
physical condition as possible at the be- 
ginning of the treatment, and this, of 
course, assumes that he is getting reason- 
ably good elimination. The various com- 
plicated preliminary methods of accom- 
plishing this seem to be largely medical 
whims, although they may be useful in 
their psychic effect upon the patient and 
perhaps just a little so upon the attending 
physician. And whether or not the phy- 
sician begins his treatment by a compli- 
cated and carefully laid out plan of pro- 
ducing elimination by a special process, or 1 
one of half a dozen methods known to 
every physician, may be left to the choice 
of the individual physician himself with 
perfect confidence that the ultimate result 
will be about the same regardless of the 
particular methods pursued. 

One method of giving the hyoscin is 
illustrated in the following case (case No. 
436), in which the patient responded in a 
characteristic manner. This patient, a 
woman thirty-five years old, of an emo- 
tional type, had been addicted to opiates 



142 OPIATE ADDICTION 

most of the time for the greater part of 
ten years. Her physical condition was 
fairly good, and at the time of beginning 
treatment she was taking four grains of 
morphin daily. 

She was admitted on the day previous 
to the day of actually beginning the active 
treatment, although she had been under 
observation for some time. The first 
evening she was given two calobarb tablets 
and a grain of morphin hypodermically. 
The following morning at six o'clock she 
was given a half ounce of magnesia sul- 
phate. Half an hour later she was given 
a grain of morphin hypodermically, as the 
bowels had moved thoroughly at that time. 
Two hours later the actual treatment be- 
gan, the first dose being given at 8.30, con- 
sisting of hyoscin 1/100 grain, pilocarpin 
1/20 grain, and heroin 1/6 grain. The 
heroin was added to the dose to avoid the 
possibility of any unnecessary pain, as she 
was a highly sensitive woman and it 
seemed particularly desirable that her suf- 
fering be minimized. 

In most cases no narcotic is necessary 



RAPID WITHDRAW ALi METHODS 143 

for this purpose, or at least only as an 
initial dose, until the hyoscin mixture has 
taken effect. Thereafter the hyoscin itself 
prevents the occurrence of pain, or at least 
it puts the patient into a "twilight sleep' ' 
in which the pain is pretty much forgotten. 

Referring to the chart, which is epitom- 
ized in part here, it will be seen that the 
patient was given twenty doses of hyoscin, 
or a total of 1/5 of a grain. Also ten 
doses of pilocarpin or a total of y 2 grain. 
She was given four doses of heroin of 1/6 
grain each and two doses of dionin of *4 
grain each, during the active stage of treat- 
ment. 

In this case the advantage of combining 
pilocarpin with the hyoscin was shown to 
advantage ; since this the patient had taken, 
or attempted to take, hyoscin treatment on 
one other occasion. At that time the treat- 
ment was not completed because the hyos- 
cin produced such dryness and pain in the 
throat that the patient refused to continue 
this treatment. With the pilocarpin added, 
however, she experienced no such difficulty, 
and as she was able to sleep most of the 



144 OPIATE ADDICTION 

time during the active treatment, her prog- 
ress was uneventful. 

It has been explained in another place 
that the hyoscin intoxication or delirium 
continues in a somewhat modified form for 
several days after the last dose of this drug 
is given. This is not an active delirium, of 
course, but more in the nature of a mild 
exaltation, or euphoria, in which the pa- 
tients may do somewhat bizarre things 
which makes it advisable to have them un- 
der fairly close observation. Frequently 
this condition is so mild in character that 
persons who are unfamiliar with the pa- 
tient's normal mental attitude would not 
observe it. 

It is in this stage that the patient often 
feels completely cured of his addiction, 
with no desire for the drug whatever, and 
anxious to leave the hospital and go about 
his business. The physician must not be 
deceived by this euphoric condition, how- 
ever. For at this time and for several 
days following, the patient is likely to have 
temporary returns of the withdrawal pains 
which incite a temporary craving for the 



RAPID WITHDRAWAL METHODS 145 

drug which would be gratified were he at 
large and acting upon his own responsi- 
bility. In short, he is still in a state of 
impaired judgment, weak willed and irre- 
sponsible as far as opiates are concerned. 

Immediately following the hyoscin ad- 
ministration some vigorous tonic and sup- 
portive treatment should be given. And 
usually the nervous system shows a reac- 
tion in which sedatives and hypnotics are 
often required. 

In the case under consideration, the pa- 
tient suffered a severe nervous shock from 
an unavoidable fright about four days 
after the treatment was discontinued. This 
fright produced a highly nervous condi- 
tion, sleeplessness, and rather severe leg 
pains. She was therefore given thirty 
grain doses of sedobrol to allay the nerv- 
ous symptoms, and the insomnia was re- 
lieved by hypodermic doses of luminal 
sodium, combined with medinal. The leg 
pains, which are always most difficult to 
control, were eased considerably by the use 
of a combination of chloretone and anti- 
pyrin. This combination of chloretone 



146 OPIATE ADDICTION 

and antipyrin makes a liquid which is read- 
ily administered in capsules. Sometimes 
five grain doses of pyramidon are useful 
for this purpose. 

In some cases great relief is given by the 
administration of five grain doses of "my- 
grone." This dose may be repeated every 
three hours if necessary to relieve the ach- 
ing legs. "Mygrone" is the trade name of 
dimethyl-amido-phenyl-pyrazolon, intro- 
duced by Filhene, and recommended highly 
for controlling certain types of pain, such 
as the leg pains of tabes. 

1st day 10:00 P.M., Calobarb 11 

10 :00 Morph. Sulph. gr. 1 

2nd day 6:00 A.M Mag. Sulph. 

" " 6:30 A.M Morph. Sulph. gr. 1 

" " 8:30 Hyoscin gr. 1/100 

" " Pilocarpin gr. 1/20 

" il Heroin gr. 1/6 

" " 10:30 Hyoscin gr. 1/100 

" " 11:00 Heroin gr. 1/6 

" " 12:30 P.M Hyoscin gr. 1/100 

" tr Pilocarpin gr. 1/20 

" " 2:30 Hyoscin gr. 1/100 

" " 4:00 Hyoscin gr. 1/100 

tl " Pilocarpin gr. 1/20 

" " 6:30 Hyoscin gr. 1/100 

il ic Heroin gr. 1/6 

" " 8:30 Hyoscin gr. 1/100 

1 1 " Pilocarpin gr. 1/20 

" " Sulphonal XX 

" " 10:30 Hyoscin gr. 1/100 



RAPID WITHDRAWAL METHODS 147 

3rd day 12:00 Heroin gr. 1/6 

1 ' " 12 :30 A.M Hyoscin gr. 1/100 

1 ' ' ' Pilocarpin gr. 1/20 

" " 2:30 Hyoscin gr. 1/100 

" " 4:30 Hyoscin gr. 1/100 

" " Pilocarpin gr. 1/20 

" " 6:30 Hyoscin gr. 1/100 

" " 8:30 Hyoscin gr. 1/100 

li " Pilocarpin gr. 1/20 

" " 10:30 Hyoscin gr. 1/100 

" tl 1:30 P.M Hyoscin gr. 1/100 

" " Pilocarpin gr. 1/20 

" " 3:00 Digitalis gr. 1/100 

11 " Dionin gr. 1/4 

" " 5:30 Hyoscin gr. 1/100 

" " Pilocarpin gr. 1/20 

li il 9:30 Hyoscin gr. 1/100 

" " 10:00 Sulphonal gr. XX 

" " 1:30 A.M Hyoscin gr. 1/100 

( l * " Pilocarpin gr. 1/20 

" " 5:30 Hyoscin gr. 1/100 

" " 8:00 Digitalis gr. 1/100 

" " Dionin gr. 1/4 



CHAPTER V. 

CHARACTERISTICS OP HYOSCIN 
DELIRIUM. 



CHAPTER V. 

CHAKACTEKISTICS OF HYOSCIST DELIRIUM. 

The chief characteristic of the hyoscin 
delirium is a feeling of depression or 
euphoria, with hallucinations and illusions 
of sight. In this condition the patient 
sees all manner of fantastic things and of- 
ten imagines that he is doing the same 
thing over and over for hours together. It 
is really a " dream state' ' with hallucina- 
tions of sight not unlike that seen in cer- 
tain other conditions, like delirium tre- 
mens, except for this very important differ- 
ence that the hyoscin hallucinations are 
frequently pleasant in character. Even 
when the things imagined would be most 
unpleasant in actuality they seldom dis- 
tress the patient and are generally re- 
garded in retrospect as ludicrous pleasant- 
ries. 

Usually the patients are restless during 

151 



152 OPIATE ADDICTION 

this delirium, frequently hyperactive, turn- 
ing and twisting constantly in the bed, or 
they may be precisely the reverse of this 
condition. And each individual patient 
develops a peculiar set of hallucinations 
that are his own and unlike those devel- 
oped by any other patient, just as each per- 
son 's dreams differ from those of his neigh- 
bor. 

Thus one patient who seemed perfectly 
happy and cheerful during the entire 
course of the treatment, imagined that he 
was wandering about on roads which led 
through great white ' ' snow banks ' ' of mor- 
phin. As soon as he left the road and at- 
tempted to gather a handful of this tempt- 
ing substance, the white banks retreated 
before him, keeping just out of reach. This 
seemed to amuse him rather than distress 
him, yet he kept persistently at it hour 
after hour, laughing and talking to him- 
self good naturedly for the greater part of 
the time. 

Another patient, a young lady, who in 
her normal state of mind had the usual 
feminine timidity about mice, imagined 



CHARACTERISTICS OF HYOSCHST DELIRIUM 153 

that on one side of her bed were thousands 
of gray mice and on the other side, count- 
less numbers of white mice. And she oc- 
cupied herself in catching these mice, cut- 
ting off their tails, and binding these tails 
into little clusters to be used as "feather 
dusters." Her delirium was of the quiet 
type and as she was resting pi bed there 
was very little suggestion of her abnormal 
mental condition. Yet when questioned, 
she would talk volubly, describing in detail 
the mouse slaughter and her methods of 
creating dusters out of the clusters of de- 
tached tails. 

Sometimes a patient is stuporous, par- 
ticularly patients that require large doses 
in order to get the desired effect. In one 
case of this kind, an extremely powerful 
athlete who had been in the habit of taking 
tremendous doses of morphin, the patient 
would sit up in bed for hours with eyes 
closed, making an occasional little furtive 
movement with his hand as if attempting 
to grasp something. Most of the time it 
was impossible to arouse him from this 
condition, and he usually resisted any at- 



154 OPIATE ADDICTION 

tempt made to change his position. Later 
on he explained that he experienced no 
pain or particularly disagreeable feeling 
during this period, but was actively en- 
gaged in picking blackberries. He would 
pick sixteen blackberries — precisely six- 
teen, no more and no less — but as soon as 
the number was reached he would take the 
berries and give them to the pigs. In this 
case the hallucinations were undoubtedly 
suggested by the fact that there were black- 
berry bushes close at hand and a pen con- 
taining some pigs a short distance away. 

Some patients engage in a great deal of 
silly laughter — a mild sort of hilarity — 
in which everything about them seems 
funny. Occasionally one becomes morose, 
querulous, irritable, and "inclined to show 
her true disposition' ' as one nurse ex- 
pressed it. But on the whole it is a not 
unpleasant delirium state, which clears up 
quickly. 

In a small percentage of cases the pa- 
tient does not clear up completely men- 
tally after the treatment is discontinued, 
but remains in a mild psycopathic state. 



CHARACTERISTICS OF HYOSCIN DELIRIUM 155 

This is sometimes attributed to the effects 
of hyoscin. But in point of fact the hyoscin 
is not responsible, since this condition oc- 
curs just as frequently when no hyoscin 
has been used. And if a careful investi- 
gation is made it usually develops that the 
patient gave evidence of a psycopathic con- 
dition before any treatment was given. It 
is sometimes a true drug psychosis, but 
more often it is a mental instability in 
which the opiate addiction is simply a con- 
tributing factor. In many cases the addic- 
tion is the result of the mental abnormality 
rather than the cause of it. 

Apparently about the most important 
period in the care of these cases is that 
immediately following the cessation of ac- 
tive treatment. At this time there may be 
no pain of any kind that would require 
treatment, and frequently no craving for 
the drug. But almost invariably there is 
a weakness and a feeling of depression at- 
tributed to this weakness, which impels the 
patient to resort to an opiate if he has the 
opportunity. 

It is at this period, usually for several 



156 OPIATE ADDICTION 

weeks after the active treatment, that the 
patient requires vigorous tonic and sup- 
portive measures as well as moral support. 
It is probable that this muscular weakness 
is due to a depletion of the endocrine 
glands, a case of hypocrinism. And if the 
opiate addiction has been of long standing 
this condition of endocrine inactively has 
become chronic and correspondingly dif- 
ficult to stimulate into normal activity. 

If this theory is correct the indication 
for treatment is to stimulate and encour- 
age the depleted glands of internal secre- 
tion as quickly as possible, and to attempt 
to replace this absence of normal secre- 
tions by the administration of artificial en- 
docrine preparations. 

To accomplish this, a vigorous adminis- 
tration of the glycerophosphates of lime 
and strychnin in combination with the ad- 
ministration of some of the mixed gland 
preparations is very useful. Nevertheless, 
it does not seem to be possible with any 
of the methods at our command at present 
to whip up the activity of the internal se- 
cretions rapidly, particularly in the old 



CHARACTERISTICS OF HYOSCIN DELIRIUM 157 

chronic cases. But the difficulty in this re- 
spect seems to be very greatly lessened if 
the patient is put through a course of pre- 
liminary treatment in which the morphin 
is reduced as much as possible and at the 
same time the internal secretions are stim- 
ulated and assisted by the administration 
of mixed gland preparations. 

The trend of practical clinical medicine 
at present is to emphasize the treatment of 
the individual patient — to study the char- 
acteristics of the patient quite as much as 
the particular disease with which he is af- 
flicted — and direct the treatment accord- 
ingly. In no condition will this principle 
prove more fruitful than in the treatment 
of opiate addiction. And in no condition 
will "cut and dried' ' methods prove more 
barren if followed with unvarying pre- 
cision. 



CHAPTER VI. 
COMMENTS AND OBSEEVATIONS. 



CHAPTER VI. 

COMMENTS AND OBSERVATIONS. 

Although the majority of opiate ad- 
dicts take their drug hypodermically, most 
of them do not use the hypodermic syringe 
for this purpose. This sounds paradox- 
ical, but it is true nevertheless. In place 
of the hypodermic syringe an ordinary eye 
dropper with a hypodermic needle slipped 
over the point is used. Some addicts pre- 
fer this to the ordinary "hypo" of com- 
merce. 

One reason for this preference is the 
difference in cost between droppers and 
hypodermic syringes. But the price is not 
always the determining factor. The sim- 
plicity of the dropper method — merely a 
glass tube with a rubber bulb at the end of 
it, in place of a complicated, piston-driven 
mechanism — appeals to the average addict. 
The mere matter of cleanliness and hygiene 

161 



162 OPIATE ADDICTION 

is of minor importance. Moreover, con- 
sidering the means usually at hand, it is 
really somewhat easier to keep an eye 
dropper clean than a hypodermic syringe, 
particularly the glass-and-metal "four 
bit" syringes carried by the average ad- 
dict. 

The art of sterilizing instruments and 
keeping them in a reasonable degree of sur- 
gical cleanliness does not seem to extend 
very much beyond medical and nursing 
circles. Yet it is an interesting fact that 
my records for the past two years show 
that fully twice as many needle abscesses 
occurred in patients who were using hypo- 
dermic syringes as in those using the eye- 
dropper method. 

However, the really astonishing thing is 
that so few abscesses occur, considering the 
manner in which the addict carries his 
drug and his apparatus for taking it, and 
the way he usually takes it. Indeed, one 
finds it difficult to understand why most 
opiate addicts fail to infect themselves con- 
tinually. Dirty morphin powder carried 



COMMENTS AND OBSERVATIONS 163 

about in dirty paper, dissolved in unster- 
ilized water, injected through uncleansed 
skin surfaces from an eye dropper and 
needle that have never been really steril- 
ized — all this suggests certain infection 
and impending death to any physician ac- 
customed to reasonable sanitary precau- 
tions. And yet many of these patients con- 
tinue to take their drug in the manner just 
described for years without producing an 
abscess. 

On the other hand, there are patients 
who continually infect themselves and who 
have one abscess after another. And fre- 
quently these are the very patients who are 
most careful in their attempts at asepsis. 
They have the latest type of glass syringe, 
are fastidious in their general habits, and 
apparently use every precaution possible 
in taking their ' i shot. ' ' And yet they pro- 
duce their regular crop of needle abscesses, 
while their unsanitary neighbor who takes 
no precautions whatever, goes abscess 
free. 

The only reasonable explanation of this 



164 OPIATE ADDICTION 

paradox is that of individual resistance. 
Some patients seem to be easily infected 
while others are practically immune. 

If the average physician were called 
upon to give a dose of medicine hypoder- 
mically without a hypodermic syringe or 
hypodermic needle, he would probably be 
somewhat nonplussed. It would be a case 
of "making bricks without straw." Yet 
any "dope fiend" can do the trick. And 
he has a special name for it — the "pin 
shot." 

The "pin shot" is an emergency meas- 
ure, indigenous to jails and other places of 
involuntary habitation, whereby dope may 
be administered without the aid of the 
usual implements. Also without the 
knowledge of the jailer. 

All the instruments necessary are a pin 
— a large safety-pin preferred — and a med- 
icine dropper. This pin is pushed ver- 
tically through the skin, making a hole 
large enough so that the solution of "dope" 
can be forced in with the fine pointed 
dropper. 

Thousands of doses of morphin are 



COMMENTS AND OBSERVATIONS 165 

taken in this way every day. The method 
is not generally recommended, even by 
those who are forced to use it. Indeed, I 
believe it is never used from choice. But 
it is effective even though inelegant. And 
it is a trick that the emergency surgeon 
might do well to remember on occasion. 

Just as the underworld of addiction has 
methods of its own so also it has a lan- 
guage of its own. This is as we would ex- 
pect when we consider that the whole life 
of this type of addict is wrapped up in his 
addiction. He thinks of nothing else, 
dreams of nothing else, and talks of noth- 
ing else in the company of his associates. 
These people seem to know each other in- 
stinctively anil are grouped together in 
inseparable clans. And when they are to- 
gether, night or day, almost the only sub- 
ject of their /conversation is "dope" — or 
"junk" as it is properly known in the ver- 
nacular. They will talk for hours of this 
or that or the other experience they have 
had, or that some one has had, or that they 
are to have. In short, their lives are en- 
tirely absorbed by their habit. And nat- 



166 OPIATE ADDICTION 

urally they have developed a jargon of 
expressions that is not found in diction- 
aries and seldom heard outside the realm 
of this particular branch of the under- 
world. 

" It is a language that no white man can 
understand/' as one of these addicts once 
told me, facetiously. "But we all under- 
stand it, the country over." 

There are certain expressions used by 
the addict that the physician should under- 
stand if he is to interpret intelligently 
what his patient is talking about. For ex- 
ample, when the addict talks about having 
a "habit" he does not refer to the taking 
of the drug, but precisely the reverse. 
When his system is calling for the drug as 
shown by yawning, sneezing, watering of 
the eye, and profuse secretions from the 
mucous surfaces, the addict describes his 
condition as a " habit, " or " yen. ' ' 

The term "habit" appears to be used 
everywhere. Wherefore, the physician 
should bear in mind that when these 
patients tell him that he has 6 i a bad habit } ' 
he does not intend to convey the impres- 



COMMENTS AND OBSERVATIONS 167 

sion that he is referring to his reprehen- 
sible drug taking, but, on the contrary, 
that he isn't getting enough of the drug 
and is suffering in consequence. 

Since practically the whole topic of con- 
versation among the majority of under- 
world addicts is something concerning their 
addiction, it is only natural that this topic 
is not confined to members of the clan alone 
at all times. Most drug takers at one 
time or another have an appreciative sense 
of shame about their addiction. At least, 
they know the attitude of the world to- 
wards their shortcoming, whatever their 
own opinion about it may be, and when in 
their normal state of mind guard their 
secret carefully. But when they have 
taken a little too much of their accustomed 
drug, or not quite enough, most of them 
tend to gabble about their affliction to 
almost anybody that comes within range. 
Thus they show the blunted condition of 
the normal sensibilities. 

"The trouble with us is," as one of them 
once told his physician, "that we talk too 
much. We know that nobody likes a 'hop 



168 OPIATE ADDICTION 

head, ' and that we would be better off if we 
kept our mouths shut about using dope. 
But when we are a little short, or have 
taken a little too much, we go and blab 
everything to everybody.' ' And this man 
spoke the truth out of the fullness of his 
experience. 

Part of the technic of drug addiction, 
when it has reached the stage at which the 
patient receives his narcotic in solution, 
is to put a small wad of absorbent cotton 
into his precious bottle of "junk." This is 
a precautionary measure, and serves a 
double purpose. For general usage it is 
helpful in preventing the needle from be- 
coming clogged if the solution is drawn 
up into the dropper or syringe through 
this absorbent cotton. And if by chance the 
bottle should be broken or its contents 
spilled, there would still be enough mor- 
phin remaining in the cotton for one last, 
life-saving shot. 

Of course, after this bit of cotton has 
been squeezed and drained, there still re- 
mains a certain amount of morphin in the 
fiber meshes which may be dissolved out. 



COMMENTS AND OBSERVATIONS 169 

Many addicts make it a practice to save 
these little pieces of squeezed out cotton, 
dry them, and put them away carefully. So 
when the inevitable " rainy day" comes, in 
which the patient finds himself short of 
medicine, he can boil up his store of im- 
pregnated cotton bits and tide himself over 
into clear weather. 

I knew of one girl who made the prac- 
tice of saving these dried bits of cotton 
against the time when she would come 
from the sanitarium after taking "cura- 
tive treatment. ' ' She had taken all manner 
of treatments at various times, and always 
reverted to the drug just about as quickly 
as possible after coming from the sani- 
tarium. And by storing these precious 
bits of cotton among her toilet articles, she 
always had on hand a daintily concealed 
supply of morphin to start her on the 
downward path just as soon as she arrived 
home. 

During her absence at the sanitarium 
her devoted parents always cleansed her 
room thoroughly and destroyed every 
grain of opiate they were able to find. But 



170 OPIATE ADDICTION 

they never suspected that the innocent 
looking little ball of cotton among their 
daughter's toilet articles was really "gun 
cotton," as she called it, that would start 
her immediately on the downward trail. 

It is a wise plan before beginning the 
actual withdrawal treatment to see that 
the patient's teeth are in good condition, 
for, if there is a cavity, or latent abscess 
or almost any other pathological condition, 
it is likely to set up a diabolical aching 
just about the time the withdrawal process 
is well under way. This is true also of 
infected nasal sinuses, chronic mastoids, 
and many other pathological conditions. 
And when we have the unpleasant with- 
drawal symptoms, which are hard enough 
to bear at best, complicated by excruciat- 
ing pains from another source, it is prac- 
tically impossible to complete the curative 
treatment for the addiction. 

Occasionally there are urgent reasons 
for giving the treatment to correct the ad- 
diction as quickly as possible regardless 
of the patient's general condition. And 
one is frequently tempted by circumstances 



COMMENTS AND OBSERVATIONS 171 

to begin the withdrawal treatment at once, 
intending to correct the other pathological 
conditions after the patient has been taken 
off the drug. Sometimes this may be done 
successfully; but as a rule it leads to dis- 
aster, as it gives the patient a very real 
excuse for reverting to his opiate. More- 
over, when the patient is suffering actual 
pain, the physician himself may be com- 
pelled to administer an opiate to relieve 
him ; and this single dose may be sufficient 
to again start the patient on the road to 
addiction. 

There is a very great difference between 
patients in the matter of the persistency 
and intensity of the craving for the drug 
once it has been permanently withdrawn. 
Some patients have a constant craving 
during every waking hour of the day, just 
as certain individuals constantly crave 
alcohol. These are the cases in which there 
is apparently something fundamentally 
lacking in their physical make-up. And 
naturally it is much more difficult for these 
patients to resist the temptation that is 
constantly present than in the case of the 



172 OPIATE ADDICTION 

person who, when once the drug has been 
withdrawn for any considerable period, 
does not experience any real craving for it. 

It is proverbial that the use of opiates 
weakens the will power. And like most 
other things proverbial, there is undoubt- 
edly a very great element of truth in this 
belief. But in a high percentage of cases 
of addiction the weakened will power is 
inherent in the individual, not merely pro- 
duced by the opiate. 

A very common mistake frequently 
made by those who have had little experi- 
ence with opiate addiction, is to assume 
that when the patient is taking a very small 
amount of the drug this can be taken away 
from the patient without producing with- 
drawal symptoms. If, for example, the 
amount of opiate has been reduced so that 
the patient is only getting one-quarter of 
a grain, or perhaps only one-eighth of a 
grain twice daily, when heretofore he may 
have been taking twenty or thirty times 
this dosage, it would seem that the abso- 
lute withdrawal of this minute quantity 
would produce no appreciable effect except 



COMMENTS AND OBSERVATIONS 173 

upon the patient's mental condition. In 
other words, if the patient did not know 
that his drug had been stopped — if he 
were to be given a hypodermic water in 
place of the narcotic — he would never know 
the difference. 

Such is not the case, however. For even 
this small amount of narcotic when sud- 
denly stopped without giving any treat- 
ment to mitigate the withdrawal symp- 
toms, will be followed by the characteristic 
series of symptoms that are shown when a 
larger amount is stopped suddenly. To 
be sure the symptoms are not so persistent 
and not quite so severe in these cases, but 
the difference is surprisingly small. And 
usually the symptoms produced by the 
withdrawal of small amounts may be miti- 
gated to a point of tolerance by the use of 
dionin or codein. But in any event, one 
should not be misled by the fallacy that no 
actual physical symptoms will be pro- 
duced by the withdrawal of minute doses of 
opiate. 

Getting up in the morning is the most 
difficult part of the day's routine for the 



174 OPIATE ADDICTION 

opiate addict. Usually he has taken a 
parting "shot" at the time of retiring the 
night before, so morning finds him with 
the effects of the opiate so greatly dimin- 
ished that he is beginning to experience 
the symptoms of withdrawal. 

The first thing on the morning's pro- 
gram, therefore, is to take a "shot to get 
up on," as he expresses it. Indeed, with- 
out this matinal stimulant most addicts 
would not be able to get up at all, or at 
best would be able to crawl about in a cold, 
clammy, nauseated condition closely ap- 
proaching complete collapse. Some pa- 
tients are so profoundly affected, particu- 
larly if they have missed their dose the 
night before, that it is almost a physical 
impossibility for them to give themselves 
a hypodermic, even with the means of 
doing so at hand. 

Having these terrible morning experi- 
ences in mind, the addict makes it a point 
to save enough "medicine" to get up on 
in the morning even though he has to omit 
his night-cap at bedtime. For although the 
sufferings of a drugless night are dis- 



COMMENTS AND OBSERVATIONS 175 

tressing enough, the morning sufferings 
and the inability to "get started,' ' are so 
much worse that the addict will undergo 
any preliminary suffering in order to avoid 
them. 

It is quite a common thing for the 
chronic opiate addict to take cocain also. 
Usually he does this so as to get the "kick" 
which opium alone now fails to give him. 
In other words, he uses cocain as a stimu- 
lant and intoxicant, whereas his opiate is 
used simply for the purpose of keeping 
himself in as nearly a normal condition as 
possible. 

Curiously enough, there is an element 
of unpleasantness in the use of cocain 
even to those persons who continue to use 
it habitually. This condition is known in 
the vernacular as the "bull horrors," a 
type of persecutory delusions in which the 
victim imagines that "some one is after 
him." He is fearful and apprehensive, 
afraid to go outside his room, afraid to 
meet people, and consumed with fear of 
some mysterious, unknown danger. And 
yet with it all he experiences a certain 



176 OPIATE ADDICTION 

kind of pleasure which more than offsets 
the terrors, so that he keeps on taking 
the cocain, knowing exactly the horrors 
that he will have to suffer, but willing to 
do so for the sake of experiencing the 
indescribable pleasure that accompanies 
the feeling. 

Of course cocain does not affect all per- 
sons in this manner ; but there is a tendency 
to produce some such effect in all cases if 
the use of the drug is persisted in for any 
considerable time. However, a notable dif- 
ference between the effects of cocain and 
the opiates is shown in the withdrawal 
symptoms. When cocain is stopped the 
patient experiences a mental craving and 
distress which is quite as insistent and 
compelling as the mental effect of opiate 
withdrawal. But the physical symptoms 
are wanting — the withdrawal of the drug 
does not produce a " habit," as the addict 
expresses it. And for this reason no par- 
ticular form of treatment is necessary, as 
it is merely a matter of keeping the cocain 
away from the patient. In these cases the 
lock-and-key method is without danger and 



COMMENTS AND OBSERVATIONS 177 

without the great discomfort that is expe- 
rienced in cases of opium withdrawal. 

One of the most dangerous elements in 
the narcotic problem is the drug-taking 
physician. For this doctor-addict not only 
has a definite motive for promoting and 
encouraging drug addiction among his 
patients, but in addition he is in a position 
to victimize entirely innocent persons. 

The imperative motive for doing this at 
present is the active enforcement of our 
narcotic laws, which makes it difficult for 
physicians to obtain any very considerable 
quantity of opiates except for legitimate 
purposes. If the addicted physician is 
taking large quantities of the drug, there- 
fore, he finds it difficult to conceal this fact 
in his record sheets, which are scrutinized 
periodically by representatives of the law. 
But if he has several habitual drug users 
among his patients, it is a comparatively 
easy matter to pervert their prescriptions, 
or divert their opiates, so that he may keep 
himself well supplied, and still have what 
appears to be clean records. Thus these 
dishonest, drug-taking members of our 



178 OPIATE ADDICTION 

profession represent an insidious agency 
for creating and perpetuating opiate ad- 
diction, particularly since the enactment of 
the recent stringent laws. These physi- 
cians were very much less of a menace in 
times gone by when it was possible for 
them to obtain all the narcotics they de- 
sired without question. 

However, the menace of the dishonest 
doctor is inconsequential in comparison 
with that of the illicit peddler. For the 
making and perpetuating of drug addicts 
is essential to the business of the drug ped- 
dler, whereas it is merely incidental with 
the addicted physician. Moreover, the 
things resorted to by the drug peddlers 
and the methods they have of spreading 
their contamination are far more compre- 
hensive than those of dishonest physicians. 
Thus, it is not only part of the peddler's 
trade to create as many drug takers as he 
can, but to keep in close contact with those 
already addicted, and to urge them on by 
the various subterfuges known to the 
members of this vulture clan. 

The drug peddler knows practically 



COMMENTS AND OBSERVATIONS 179 

every chronic opiate addict in his immedi- 
ate community. Also, most of the drug 
addicts, at least in the underworld, know 
him, and hate him — but fear him. They 
know that even though they are not pur- 
chasing their drug regularly from him, he 
will "help them out" in the " emergen- 
cies " that arise inevitably. Or he can 
refuse to do so, and cast them into the 
slough of unspeakable torment and tor- 
ture if he so wills. Wherefore, they refuse 
to divulge his identity to the officers even 
when subjected to third degree methods, 
though their hatred of the creature they 
defend is such that they would glory in 
knowing he was being torn limb from limb. 
This is one of the complicating problems 
of the present narcotic situation. 

It is a gloomy day for the narcotic ped- 
dler when he hears that one of his erst- 
while patrons has entered a sanitarium for 
the treatment of addiction. It is a gloomy 
day, but not one of utter despair. For the 
peddler has passed through these periods 
of uncertainty and depression before, and 
knows that he still holds a very important 



180 OPIATE ADDICTION" 

trump card which he will play, with more 
than even chances of success, after a short 
period of patient waiting. 

Here is an illustration of what this 
trump card is, and how he uses it : A cer- 
tain patient who had been ^addicted to 
opiates for several years sought out a 
reputable and highly successful sani- 
tarium and submitted herself to their 
treatment for the cure of addiction. The 
treatment was eminently successful and 
was completed without incident. And after 
the usual period the patient returned to 
her home, pleased with herself and the 
world in general, and without any im- 
pelling craving for an opiate more than is 
always present in any person who has ever 
been really addicted. 

Within four hours after reaching home 
she received a telephone message from a 
former acquaintance who was addicted to 
drug-peddling, offering to sell her a supply 
of morphin at a price very much less than 
the illicit market value. The offer was re- 
fused. A few hours later she was again 
called to the 'phone by the same person, 



COMMENTS AND OBSERVATIONS 181 

who offered her the same amount of mor- 
phin as before, but at half the price previ- 
ously quoted. This offer was refused also. 
The following morning, just at the time 
when the drug addict is likely to have the 
most insistent craving, she was again called 
to the 'phone and was again offered a 
tempting half dram of the opiate, this time 
without any question of price, but simply 
as a gift. And still she refused. 

At noon, however, she received another 
telephone message from the same persis- 
tent peddler. In this conversation she was 
informed that if she would look under the 
right hand corner of the door-mat at her 
front door, she would find a paper contain- 
ing a half dram of morphin placed there 
at her disposal by the peddler. And when 
the patient resisted this temptation for 
several hours, the peddler called up his 
victim and requested that she sit in her 
window where she could watch her front 
doorstep and witness him go to the door- 
mat, take out the tempting paper and ex- 
hibit it to prove the truth of his assertion, 
and then replace it and go his way. 



182 OPIATE ADDICTION 

This incident illustrates the persistency 
of the peddler in plying his trade. His 
motive is obvious. He could well afford to 
give away a half dram of morphin, know- 
ing that this amount would quickly estab- 
lish a condition of addiction in his victim 
that would reap him a rich harvest in 
profits later on. 

It should be recorded to the credit of 
this particular opiate addict that after this 
last episode of the door-mat, she threw 
discretion to the winds and called up the 
police authorities. But it so happened that 
the department in charge of the narcotic 
problem had no officers available for the 
moment, and, as it was late Saturday after- 
noon, she found it impossible to get in 
touch with the State officers to whom she 
appealed. And meanwhile, remember, 
there was that great temptation tantaliz- 
ing her from her very door-step. Need 
any one question the ultimate result? 
Within a week's time the peddler had 
wiped out his losses, and was checking up 
his usual profits on the credit side. 

This case illustrates one of the phases 



COMMENTS AND OBSERVATIONS 183 

of the menace of the illicit peddler, and the 
kind of shrewdness the authorities are 
obliged to contend with continually. It 
illustrates also the human side of the 
chronic addict, even when in deadly earnest 
about overcoming the habit. The peddler 
reckoned with this weakness when he 
found that his intended victim would 
listen, even though she refused. For he 
knew that in these cases, as in the case of 
Byron's estimate of another human 
frailty, "who listens once will listen twice, 
and one refusal no rebuff." 

Any one who is inclined to criticise too 
harshly the addicted person's inability to 
resist temptation (and most of us are so 
inclined), should take stock of the amount 
of resistance to temptation offered by the 
average individual as regards less baleful 
bad habits than opiate taking. Smoking, 
for example, and the eating of too much 
food by fat persons. 

We know that about ninety-nine per 
cent, of fat persons are fat simply because 
they eat too much. And a very high per- 
centage of persons, in these days of luxury, 



184 OPIATE ADDICTION 

are too fat. It is a matter of common 
knowledge that too much fat is bad for the 
health, and it is a matter of common obser- 
vation that too much fat is disfiguring. 
Also, fat is a source of constant discom- 
fort. And so we have three impelling mo- 
tives for not being fat, — health, comfort, 
and appearance. Yet we know that there 
is not one person in a thousand who will 
resist the temptation to take a "second 
helping" and to eat those tempting things 
that one especially likes. 

When we consider that there is much 
truth in the ancient jest that "nobody likes 
a fat man"; and absolute truth in the 
belief of every woman that nobody likes the 
appearance of a fat woman; and that ap- 
pearances are almost the dearest things 
that the world offers a woman ; and, more- 
over, that almost any fat woman can re- 
vert to comely slenderness by persistent 
dieting — when we consider all these things, 
and then reflect that even with this array 
of compelling incentives it is almost im- 
possible to find any person who will really 
diet consistently, it is not surprising that 



COMMENTS AND OBSERVATIONS 185 

the drug addict does not show himself to 
be a paragon quite above the common herd 
in his human attributes by resisting a 
temptation of far greater intensity than 
the mere desire for a special kind or qual- 
ity of food. 

It is a matter of common observation 
that the institutions that charge the 
highest rate, and the physicians who de- 
mand the highest fees for their services, 
are the most successful in the treatment 
of drug addiction. Why? It is a question 
readily answered by the psychologist. 
First of all, most human beings value 
things for what they cost. This rule holds 
true when a person gets something for 
nothing. Or, at any rate, his estimation 
of the value is likely to be far higher if 
he has been obliged to toil and sacrifice 
for a thing. Wherefore, it follows as a 
natural consequence that the opiate addict 
who has sacrificed both money and comfort 
for his treatment is far more likely to re- 
sist the temptation to return to his addic- 
tion than the one who has made compara- 
tively little sacrifice. This is discourag- 



186 OPIATE ADDICTION 

ing, for it lessens the value of any treat- 
ment that is given gratuitously. And yet 
most cases of opiate addiction fall in the 
charity class. 

We must bear in mind, of course, that 
the moral fiber and intelligence of the 
patients who patronize expensive institu- 
tions and physicians are of better quality 
on the average than those of charity cases. 
Their natural endowments are better, and 
we would expect a higher percentage of re- 
coveries among this class of patients under 
any circumstances. Nevertheless, the gen- 
eral proposition holds true that those who 
work, and earn, and pay for things appre- 
ciate those things more than those who 
receive them as gifts. And the practical 
truth of this is suggested by the fact that 
most charity cases require custodial care 
as well as medical treatment for the cure 
of their addiction. 



INDEX 



Abscesses, from use of hypo- 
dermic syringe and its sub- 
stitutes, astonishingly rare 
among addicts, 162. 

Acidosis, a usual complication 
in drug addiction, 61. 

Addict, "cured" against his 
will, is not cured at all, 
56; 
under treatment should be 
kept in ignorance of what 
he is taking, 69 ; 
the most sophisticated of pa- 
tients, 110. 

Addiction, drug, not a mere 
"habit," 8; 
likened to inebriety, 9 ; 
see also Drug Addiction. 

Addicts, dishonest, often vic- 
timize physicians, and se- 
cure excess supplies of the 
drugs, 20 ; 
reputable, suffer hardships be- 
cause of the dereliction of 
dishonest addicts, 20. 

Ambulatory treatment, of drug 
addicts, not favored by the 
Federal Government, 17. 

Antipyrin, in combination with 
chlovetone, sometimes use- 
ful to relieve leg pains of 
withdrawal, 146. 



Asylum for the insane, in Mid- 
dle West, a successful 
method of gradual reduc- 
tion practised in, 26 ; 
asylum treatment, some of its 
disadvantages, 37. 

Atropin group, as substitutes, 
can alleviate cravings of 
opiate addicts, 51. 



B 

Belladonna, in combination with 
xanthoxylin and hyoscya- 
mus, as used in the Lam- 
bert-Towns method of rapid 
withdrawal, 125. 

Bishop, The Narcotic Drug 
Problem; summary of his 
presentation of symptoms 
of withdrawal of narcotics, 
characterising the "nar- 
cotic drug addiction dis- 
ease," 4 ; 
expresses consensus of opin- 
ions of clinicians as to 
gradual withdrawal, 47 ; 
outlines principles of with- 
drawal treatment, 134. 

Blue mass with compound ca- 
thartic pills, as used in the 
Lambert-Towns method of 
rapid withdrawal, 126. 



187 



188 



INDEX 



Calomel, with cascara and ipe- 
cac used in the Pettey 
method of rapid withdrawal, 
129. 

Characteristics of Hyoscin De- 
lirium ; Chapt. V, 151. 

Chart of a case treated suc- 
cessfully by gradual with- 
drawal, 67. 

Chloral hydrate, a time-honored 
and still useful and effec- 
tive hypnotic, 104. 

Chloretone, a mild but useful 
hypnotic, 104 ; 
and antipyrine in combina- 
tion, sometimes useful to 
relieve leg pains incident 
to withdrawal, 145. 

Christian Science, and drug ad- 
diction, 8. 

Cocain, often taken by the 

opiate addict, 175 ; 

addiction ; its symptoms, 175 ; 

withdrawal of the drug does 

not produce a "habit," 

176. 

Codein addiction, practically 
unknown, 50 ; 
and dionin, have toxic effect 
in weak or attenuated 
form, 49 ; 
can relieve the cravings of 
the addict, when morphine 
and heroin are not avail- 
able, 50 ; 
in treatment of withdrawal 
symptoms, 122. 

Clandestine sale of drugs, al- 
most universal, 18. 

Comments and Observations ; 
Chapt. VI, 161. 

Common-sense applied to treat- 
ment of drug addicts, 58. 



Compound cathartic pills and 
blue mass, as given in the 
Lambert-Towns method of 
rapid withdrawal, 126. 

Constipation, usual with drug 
addicts, 61. 

Cough mixtures, containing opi- 
ates, a source of relapse, 7. 

Cure of drug addiction, skepti- 
cism regarding its perma- 
nence, 13. 



Dial-Ciba, one of the most use- 
ful and least harmful hyp- 
notics, 98. 

Digitalis, preferably given hy- 
podermically, useful where 
weakness develops during 
withdrawal, 120. 

Dimethyl-amid-phenyl - pyrazalon 
("Mygrone"), sometimes 
useful to relieve leg pains 
during withdrawal, 146. 

Dionin, can be substituted on 
occasions for morphine or 
heroin, 50 ; 
addiction, practically un- 
known, 50 ; 
and codein, less toxic than 
morphine and heroin, 49. 

Dose, an enormous, of hyoscin 
taken by an addict without 
permanent injury, 86. 

Doses, number to be given daily,- 
in gradual reduction, 73. 

Drug addiction, likened to ine- 
briety : neither is depend- 
ent primarily on opportu- 
nity alone, 10 ; 
sometimes apparently the re- 
sult or manifestation of a 
pre-existing psychosis, 11 ; 



INDEX 



189 



Drug addiction, unlike inebriety, 

is not intermittent, 11 ; 
not always the result of un 

stable nervous organization 

12; 
no constitution gives entire 

immunity from danger, 12 
skepticism as to possibility 

of permanent cure, 13 ; 
importance of good nursing in 

treatment, 109 ; 
and Christian Science, 8. 
Drug addicts, often abnormal, 

or actually insane, after 

cure, 11 ; 
difficulty of deceiving with 

"sterile hypo," 29 ; 
blameless, exist by thou- 
sands, 33. 

E 

Endocrine depletion, as possible 
complication, 23 ; 

Endocrine extracts, sometimes 
administered to advantage 
during withdrawal of drugs, 
23; 
sometimes useful in prelimi- 
nary treatment, 116 ; 
in combination, useful in 
after treatment, 156. 



Federal law, requires indorse- 
ment of each prescription 
by the person receiving the 
drugs, 70. 

"Feel" of the needle may be- 
come almost an addiction, 
53. 



Glycerophosphates of lime and 
strychnine and mixed en- 
docrine glands useful in 
after treatment, 156. 
Gradual Reduction Treatment, 
Chapt. II, 17; 

sometimes the method of 
choice, where tuberculosis 
is a complication, 21 ; 

a successful case detailed, 22 ; 

why should it be attempted 
at all ? 32 ; 

illustrated by selected cases, 
38; 

futile with a certain number 
of cases under any circum- 
stances, 41 ; 

strychnine the most useful 
single drug in, 59 ; 

milk of magnesia or bicarbi- 
nate of soda and cascara to 
correct acidosis and con- 
stipation, 61 ; 

chart of successful case, 67 ; 

number of doses daily, 73 ; 

by oral administration, details 
of, 75; 

chart for case No. 297, 78 ; 

the use of hyoscine and pilo- 
carpin at a later stage, 82 ; 

rapidity of reduction not de- 
termined by any fixed rule, 
88; 

a method of, as practised in 
an asylum in the Middle 
West, 26; 

usually does not call for any 

preparation of hyoscyamus, 

84. 

Gradual withdrawal, as viewed 

by Dr. Bishop, who ex- 



190 



INDEX 



presses the consensus of 
opinion of clinicians, 47. 



"Habit" or "yen" in the termi- 
nology of the addict, refers 
to craving for or need of 
the drug, 166. 

Heroin and morphine the drugs 
chiefly responsible for ad- 
diction, 49. 

Hospital treatment, always to 
be desired, 112. 

Hot baths sometimes useful as a 
sedative, 118. 

Hyoscyamus and its derivatives, 
not usually called for in 
treatment by gradual with- 
drawal, 84 ; 
the basis of rapid-withdrawal 
treatment, 138. 

Hyoscyamus, in combination 
with xanthoxylin and bella- 
donna, as used in the 
Lambert-Towns method of 
rapid withdrawal, 125. 

Hyoscin, the best drug of the 
atropin group to relieve 
the cravings of the drug 
addict, 51. 

Hyoscin, used with pilocarpin 
in later stages of a case 
treated by gradual reduc- 
tion, 82 ; 
something of a medical buga- 
boo, 84 ; 
enormous doses borne by an 

addict, 86 ; 
the essentials of its use in 
withdrawal treatment, 139 ; 
administration ; an illustra- 
tive case, 141 ; 



Hyoscin, combined with pilo- 
carpin, etc., in withdrawal ; 
chart of an illustrative 
case, 146. 

Hyoscin delirium, characteris- 
tics of; Chapt. V, 151. 

Hypnotics, Useful ; Chapt. III. 
97. 

Hypodermic syringe, substi- 
tutes for, as used by ad- 
dicts, 161. 

I 

Ice bag, to head, sometimes use- 
ful along with hot baths 
for sedative effects, 118. 

Ideal case for treatment, seem- 
ingly, may prove utterly 
intractable, 43. 

Ideal conditions for gradual 
reduction treatment re- 
quire patient to be under 
lock and key, 31. 

Illicit peddler of drugs, an in- 
tolerable but ever-present 
menace, 178. 

Inebriety, likened to drug addic- 
tion, 9 ; 
unlike drug addiction in that 
it is often periodic, 11. 

Ipecac, in combination with 
calomel, etc., used in the 
Pettey method of rapid 
withdrawal, 129. 

Isolation, absolutely essential to 

successful treatment with 

some types of cases, 40 ; . 

essential when other members 

of a family are addicts, 45. 



Lambert-Towns method of rapid 
withdrawal, by substitution 



INDEX 



191 



of belladonna, xanthoxylin, 
and hyoscyamus, 124. 

Laudinum-drinking ; its rela- 
tion to treatment, 76. 

Law, Federal, as to indorsement 
of prescriptions, 70. 

Leg pains, a prominent symptom 
of withdrawal, sometimes 
controlled by a combination 
of chloretone and antipyrin, 
145 ; or by "mygrone," 146. 

Luminal and luminal sodium, 
useful hypnotics in selected 
cases, 102. 



Magnesia, milk of, useful to cor- 
rect acidosis and constipa- 
tion, 61. 

Massage, a useful adjunct of 
treatment, 119. 

Mediaeval idea of the value of 
suffering has no place in 
modern therapy of drug 
addiction, 122. 

Medicine dropper, as a substi- 
tute for the hypodermic 
syringe, 161. 

Medinal, a useful hypnotic, 99. 

Mental instability, often but 
not always a concomitant 
of drug addiction, 12. 

Michael Angelo's rule about tri- 
fles, applied to treatment 
of the addict, 56. 

Morphin, administered to gassed 
soldiers, led to addiction in 
many cases, 33 ; 
and heroin, chiefly responsible 
for addiction, 49. 

Moral fibre and intelligence of 



the patient are factors in 
prognosis, 186. 
"Mygrone" sometimes useful to 
relieve pain during with* 
drawal. 146. 



N 

Narcotic drugs, of all kinds, are 
borne in large doses by ad- 
dicts, 60. 

Neurotic types and drug addic- 
tion, 12. 

Nurse, the, almost as important 
as the physician in treating 
drug addiction, 109. 

Nurses, lacking experience with 
mental cases, almost use- 
less in treatment of drug 
addiction, 110. 



Opiates, same initial doses pro- 
duce different sensations in 
different individuals, 13 ; 

clandestinely sold almost 
everywhere, complicating the 
problem of treatment, 18. 
Opiate-addiction, defined, 3. 

symptoms of, manifested 
through withdrawal of the 
drug, 4 ; 

centuries old, and the subject 
of much difference of opin- 
ion, 25 ; 

see also Drug addiction. 
Opium-sensitization, comparable 
to sensitizations to rhus 
(poison oak) and other 
toxic substances, 14. 



192 



INDEX 



Opium-smoking, a method used 
by older addicts ; its rela- 
tion to treatment, 76. 

Oral administration, as substi- 
tute for hypodermic, not 
always feasible, 53 ; 
sometimes combined with hy- 
podermic, 54. 



Paraldehyde, sometimes a useful 
hypnotic, 103. 

Peddler of drugs, an ever- 
present menace ; his per- 
sistency illustrated, 180. 

Pettey method of rapid with 
drawal, 128. 

Physician, the drug taking, a 
dangerous element in the 
narcotic problem, 177. 

Physicians, often victimized by 
dishonest addicts, 20. 

Pilocarpin hydrobromate, in 
combination with scopola- 
min, diomin, and cascara, 
as used in the Sceleth 
method of rapid withdrawal, 
132; 
used with hyoscin in later 
stages of treatment of a 
case by gradual reduction, 
82. 

Preparatory treatment, before 
withdrawal, essential in 
some cases, 40. 

Preliminary treatment, is usu- 
ally required, 115. 

Prognosis, often very difficult, 
43. 

Psychoses, often manifested by 
drug addicts, even after 
cure, 11. 



R 

Rapidity of reduction, deter- 
mined by law in certain 
states, 89. 
Rapid Withdrawal Methods ; 
Chapt. IV, 109; 
The Lambert-Towns method 

detailed, 124 ; 
The Pettey method using sco- 
polamin, spartein, and so- 
dium thiosulphate, 128 ; 
the Sceleth method, using 
scopolamin, pilocarpin, dio- 
nin, and cascara, 131 ; 
Bishop's principles of treat- 
ment, 134 ; 
abstract of an illustrative 
case, 146. 
Rhus poisoning, sensitization to ; 
comparable to opium sensi- 
tization, 14. 
Rural and village cases usu- 
ally more hopeful than 
urban cases, 44. 

S 

Safety pin, as a substitute for 
hypodermic syringe, 164. 

Sceleth method of rapid with- 
drawal, 13 L 

Scopolamin in combination with 
spartein and sodium thio- 
sulphate, as used in the 
Pettey method of rapid 
withdrawal, 128 ; 
as used in combination with 
pilocarpin, dionin, and cas- 
cara in the Sceleth method 
of rapid withdrawal, 132. 

Sedobrol, to allay the nervous 
symptoms in withdrawal 
treatment, 145. 



INDEX 



193 



Sensitization to opiates, com- 
parable to sensitization to 
rhus poisoning 1 , 14 ; 
retained by addicts after ap- 
parent return to normal, 7. 

Skepticism of the authorities 
fostered by acts of dishon- 
est addicts, 20. 

Slow reduction, not ordinarily 
the "method of choice," 17 ; 
see Gradual reduction treat- 
ment. 

Sodium bicarbonate, combined 
with cascara, useful to cor- 
rect acidosis and constipa- 
tion in treatment of addic- 
tion, 61. 

Sodium bromide, sometimes use- 
ful in mild cases, 118. 

Sodium thiosulphate, in combi- 
nation with scopolamin and 
spartein, as used in the 
Pettey method of rapid 
withdrawal, 128. 

Soldier-addict, presenting a dim- 
cult problem as to treat- 
ment, 33 ; 
details as to successful treat- 
ment, 61. 

Soldiers sometimes become ad- 
dicts through having mor- 
phin administered to re- 
lieve suffering from gas- 
sing, 33. 

Solutions, why preferable to 
tablets or powders, 65. 

Spartein sulphate, in combina- 
tion with scopolamin and 
sodium thiosulphate, as 
used in the Pettey method 
of rapid withdrawal, 128. 

Strychnin, used in gradual with- 
drawal method, as practised 



in an asylum for the in- 
sane, 28 ; 
the most useful single drug in 
treatment by gradual re- 
duction, 59 ; 
and digitalis, as used in the 
Lambert-Towns method of 
rapid withdrawal, 128. 

Substitutes for the hypodermic 
syringe, as used by addicts, 
161. 

Substitution, as practised in 
gradual withdrawal method, 
40. 

Sudden reduction, sometimes 
fails where gradual with- 
drawal proves feasible, 22. 

Sulphonal, a most satisfactory 
all-around hypnotic, 100. 

Symptoms of withdrawal of nar- 
cotics, as presented by 
Bishop, 4. 



Temperamental differences in 
patients, 117. 

Time required for withdrawal 
by gradual reduction meth- 
ods, 27. 

Tolerance of opiates, variations 
as to, among normal indi- 
viduals, 92. 

Tuberculosis, a complication to 
be borne in mind, 20. 

U 

Useful Hypnotics, Chapt. Ill, 

97. 
Urban cases, less hopeful for 

treatment than village and 

rural cases, 44. 



194 



INDEX 



Veronal, a useful hypnotic, 101. 
Village cases, more hopeful for 

treatment than city cases, 

44. 

X 
Xanthoxylin, in combination 

with belladonna and hypos- 



cyamus, as used in the 
Lambert-Towns method of 
rapid withdrawal, 125. 



"Yen" or "habit" in addict 
terminology, refers to need 
of the drug, 166. 



